Citation
U.S. Army Medical Department journal

Material Information

Title:
U.S. Army Medical Department journal
Alternate title:
United States Army Medical Department journal
Alternate Title:
AMEDD journal
Running title:
Army Medical Department journal
Abbreviated Title:
U.S. Army Med. Dep. j.
Creator:
United States -- Army Medical Department (1968- )
Place of Publication:
Fort Sam Houston, TX
Publisher:
U.S. Army Medical Department
Publication Date:
Frequency:
Quarterly[<Oct.-Dec. 2001->]
Bimonthly[ FORMER Sept.-Oct. 1994-]
quarterly
regular
Language:
English
Physical Description:
volumes : illustrations ; 28 cm

Subjects

Subjects / Keywords:
Medicine, Military -- Periodicals -- United States ( lcsh )
Military Medicine ( mesh )
Medicine ( mesh )
Medicine, Military ( fast )
United States ( mesh )
United States ( fast )
United States
Genre:
Electronic journals.
Periodicals.
Periodicals. ( fast )
Fulltext.
Government Publications, Federal.
Internet Resources.
serial ( sobekcm )
federal government publication ( marcgt )
periodical ( marcgt )
Electronic journals ( lcsh )
Periodicals ( mesh )
Periodicals ( fast )
Fulltext
Government Publications, Federal
Periodicals
Internet Resources

Notes

Dates or Sequential Designation:
Sept.-Oct. 1994-
General Note:
Title from cover.

Record Information

Source Institution:
University of Florida
Holding Location:
University of Florida
Rights Management:
This item is a work of the U.S. federal government and not subject to copyright pursuant to 17 U.S.C. §105.
Resource Identifier:
32785416 ( OCLC )
98642403 ( LCCN )
1524-0436 ( ISSN )
ocm32785416
Classification:
RC970 .U53 ( lcc )
616.9/8023/05 ( ddc )
W1 JO96 ( nlm )

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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AprilJune2006Perspective1MGGeorgeW.WeightmanPreventionistheBestWaytoHealth3BGMichaelB.CatesTheEvolutionofPublicHealthEducationintheUSArmy,1893-19667COLStephenC.Craig,MC,USATheEvolvingRoleofEnvironmentalScienceOfficersand18EnvironmentalEngineersintheMedicalServiceCorpsCOLJohnJ.Ciesla,MS,USAArmyEpidemiologyandHealthSurveillance22COLBrunoPetruccelli,MC,USA;Dr.JosephKnapik,ScDVectorControlandPestManagement31LTCMustaphaDebboun,MS,USA,etalFieldPreventiveMedicine:ChallengesfortheFuture40LTCWilliamJ.Sames,MS,USA,etalDeploymentOccupationalandEnvironmentalHealthRiskManagement46COLRobertR.Eng,MS;USA;COL(Ret)CurtisW.Pearson,MSC,USAFDeploymentOccupationalandEnvironmentalHealthSurveillance:50EnhancingtheWarFightersForceHealthProtectionandReadinessJeffreyS.Kirkpatrick;LTCChristineMoser,MS,USA;BradE.Hutchens,PEMakingtheModernArmyPublicHealthNurse:61EstablishingEssentialServiceSkillsMAJJamesA.Madson,MS,USA;LTCBryanJ.Alsip,MC,USAForceHealthProtectionThroughLaboratoryAnalysis66andHealthRiskAssessmentMAJPattersonW.Taylor,MS,USA,etalBullisFever:AFleetingEpidemicofUnknownEtiology73LTCMichaelJ,Zapor,MC,USA F O R C E H E A L T H P R O T E C T I O N A N D P R E V E N T I V E M E D I C I N E

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LTGKevinC.Kiley TheArmySurgeonGeneral Commander,USArmyMedicalCommandMGGeorgeW.WeightmanCommandingGeneral USArmyMedicalDepartmentCenterandSchool AprilJune2006 TheArmyMedicalDepartmentCenter&School PB8-06-4/5/6 0608803 PETERJ.SCHOOMAKER General,UnitedStatesArmy ChiefofStaff DISTRIBUTION:Special AdministrativeAssistanttothe SecretaryoftheArmy ByOrderoftheSecretaryoftheArmy: Official: JOYCEE.MORROW Onlineissuesofthe AMEDDJournal areavailableathttps://secure-akm.amedd.army.mil/dasqaDocuments.aspx?type=1 AProfessionalPublication oftheAMEDDCommunity The ArmyMedicalDepartmentJournal [ISSN1524-0436]ispublishedquarterlyfor TheSurgeonGeneralbytheUSArmyMedicalDepartmentCenter&School,ATTN: MCCS-DT,2423FSH-HoodST,FortSamHouston,TX78234-5078. CORRESPONDENCE: Manuscripts,photographs,officialunitrequeststoreceive copies,andunitaddresschangesordeletionsshouldbesenttothe Journal atthe aboveaddress.Telephone:(210)221-6301,DSN471-6301 DISCLAIMER: The Journal presentsclinicalandnonclinicalprofessionalinformation toexpandknowledgeofdomestic&internationalmilitarymedicalissuesand technologicaladvances;promotecollaborativepartnershipsamongServices, components,Corps,andspecialties;conveyclinicalandhealthservicesupport information;andprovideapeer-reviewed,highquality,printmediumtoencourage dialogueconcerninghealthcareinitiatives. Viewsexpressedarethoseoftheauthor(s)anddonotnecessarilyreflectofficialUS ArmyorUSArmyMedicalDepartmentpositions,nordoesthecontentchangeor supersedeinformationinotherArmyPublications.The Journal reservestherighttoedit allmaterialsubmittedforpublication(seeinsidebackcover). CONTENT: Contentofthispublicationisnotcopyrightprotected.Materialmaybe reprintedifcreditisgiventotheauthor(s). OFFICIALDISTRIBUTION: ThispublicationistargetedtoUSArmyMedical Departmentunitsandorganizations,andothermembersofthemedicalcommunity worldwide.

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AprilJune20061PerspectiveMajorGeneralGeorgeW.Weightman ThiswillbemylastissuetoreviewastheCommandingGeneral,ArmyMedicalDepartmentCenterandSchoolandFortSamHoustonandIwanttothankallofthereadersandcontributorsfortheirinterestandintellectualrigorinmakingthisJournalamorerelevantandrespectedpublicationoverthelasttwoyears.ThebreadthanddepthoftheissueswehavecoveredhavebeenindicativeofhowcomplextheAMEDDhasbecomeasweconstantlystrivetosupporttheWarfighter.AllofusattheCenterandSchoolappreciateyoursupportandIencourageyoutocontinuetoconductandreportonyourresearchaswealldoourverybesttobroadentheknowledgebaseofallofourWarriorMedics.TheAMEDDJournalisanimportantvenuetohelpusallunderstandthebigpictureaswellasbrushuponourownspecialties.IthinkyouwillfindthiseditionoftheAMEDDJournalparticularlyusefulandinformational.ThisissuesfocusisonPreventiveMedicineandImsureyouwillallfindthatthearticleswillexposeyoutoareasofthisspecialtywhichyouwerenotfamiliarwith.WhatmakesthistopicparticularlyrelevantaswefindourselvesinourfifthyearoftheGlobalWaronTerrorismiswhatatremendousimpactourpreventivemedicineinitiativesaremaking,andhowtheyhavedrasticallychangedtheepidemiologyofthecasualtiesweareseeinginjustafewyearsofintensiveeffort.ThisissueiskickedoffbyacapstonearticleonpreventivemedicinebyBGMichaelCates,theCommandingGeneraloftheUSArmyCenterforHealthPromotionandPreventiveMedicine.WithPreventionistheBestWaytoHealth,BGCatesgivesusabrieflookatthehistoryandbackgroundofmilitarypreventivemedicine,notesthecurrentstatus,andoffersupseveralconsiderationsforfutureendeavors.Heremindsusthat97%ofournationshealthcaredollarsarespentonrestorativecarewhileonly3%aredesignatedforgovernmentpreventivemedicineprograms.OurDiseaseandNonbattleInjuryhospitalizationratesforOperationsIraqiFreedomandEnduringFreedomarelessthan10%ofwhattheywereinWorldWarIIandKorea.Thisisagreatoverviewandeasyread.TheEvolutionofPublicHealthEducationintheUSArmy,1893-1966byCOLStephenCraigtracesthepreventivemedicineresidencyprogramandhowitparalleledcivilianpublichealtheducation.Ofparticularnoteisthatwelearnthatin1893SurgeonGeneralBGGeorgeSternbergestablishedtheArmyMedicalSchoolinWashington,DCwithanemphasisonpublichealth.ThissameschoolevolvedintoourmoderndayWalterReedArmyInstituteofResearch.Finally,hedocumentswellthepersistentconflictsbetweenPreventiveandClinicalMedicinethroughthelast100+years.TheEvolvingRoleofEnvironmentalScienceOfficersandEnvironmentalEngineersintheMedicalServiceCorpsbyCOLJohnCieslahelpsallofusunderstandhowbothspecialtiesevolvedandhowtheydifferintheiracademicpreparation,backgrounds,andprimaryfocus.HenotesthepresentincreaseddemandforbothspecialtiesaswegetmoreconcernedaboutSoldierexposuretoenvironmentaltoxins.ThegreatnewsisthatthereisacontinuedstrongdemandforbothinthenewArmyformationsbeingcreatedunderTransformation.

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2ArmyMedicalDepartmentJournalArmyEpidemiologyandHealthSurveillancebyCOLBrunoPetruccelliandDrJoeKnapikstartsbydefiningbothconceptsandthenproceedswithabriefhistoryofboth.TheauthorsremindusthattheArmyistheExecutiveAgentforalltheDepartmentofDefenseforhealthsurveillance,anddoesagreatjobtellingushowwereusingsuchtoolsasDOEHRS*andGEIStoaccomplishtodaysverycomplexandsophisticatedbattlefieldsurveillancemission.VectorControlandPestManagementbyLTCDebbounetalprovidesuswithanoverviewoftherelevance,scope,andagenciesinvolvedinDoDVectorControlandPestmanagement.Hegivesusallatimelyreminderthatthecornerstoneoftheseprogramsispersonalprotectivemeasures.FieldPreventiveMedicine:ChallengesfortheFuturebyLTCSamesetalgivesusabriefdescriptionofthemanningavailabletoaccomplishoperationalfieldsanitation,fromindividualsoldiers,toFieldSanitationTeams,tothemultipleAMEDDspecialistsavailable.Hepointsoutseveraldrawbacksofthecurrentmanning/trainingandpointsoutafewfuturechallengestoimproveourpresentsystems.DeploymentOccupationalandEnvironmentalHealthRiskManagementbyCOLRobertEngandCOL(ret)CurtisPearson,startsbygivingusabriefhistoryoftheDeploymentOccupationalandEnvironmentalHealthRiskManagementprogramandthenfurtherdescribesseveralexistingandplannedinitiatives.Interestingly,theypointoutthatthisinitiativegrewoutofourdeficienciesindealingwiththeissuesfromourveteransreturningfromOperationDesertStorm.DeploymentOccupationalandEnvironmentalHealthSurveillance:EnhancingtheWarFightersForceHealthProtectionandReadinessbyJeffreyKirkpatricketalbasicallylaysoutthethreeprogramswhichcomprisetheDirectorateofHealthRiskManagement.Theseinclude1)theGlobalThreatAssessmentProgramwhichidentifiesandassessesdeploymentOccupationandEnvironmentalhazardsandthreatsworldwide.2)TheDeploymentEnvironmentalSurveillanceProgramwhichprovidescommandersreach-backcapabilityforenvironmentandoccupationalissues,informsthemofpresenthealthrisksassociatedwiththeiroccupationsandenvironment,andgivesthemactualexposuredata.3)TheDeploymentDataArchiveandPolicyIntegrationProgramistheinformationtechnologysystemwhichcapturesandarchivesoccupationalandenvironmentalhealth(OEH)dataandhelpswithintegrationofOEHintotheDOTMLPFmodelmethodology.MakingtheModernArmyPublicHealthNurse:EstablishingEssentialServiceSkillsbyMAJJamesMadisonandLTCBryanAlsiptracestheevolutionoftheCommunityHealthNursefromtheiroriginalfocusonassistingnewparentsadjusttofamilylife,tobeingresponsibleformanycommunityprograms,totheircurrentprofessionaltrainingandassignmentsintheincreasedresponsibilitiesofapublichealthofficial.Inrecognitionoftheirnewskillsandresponsibilities,theirtitlehasbeenchangedPublicHealthNurse.ForceHealthProtectionThroughLaboratoryAnalysisandHealthRiskAssessmentbyMAJPattersonTayloretaldescribestheuniquecapabilitiesofthe1stand9thAreaMedicalLabs,whicharetheonlyArmydeployablelabswitharobustanalyticalcapabilitytoprovidehealthhazardsurveillancewitharemarkableshortresponsetime.Finally,BullisFever:AFleetingEpidemicofUnknownEtiology,byLTCMichaelZaporisamedicalWhoDunIt?mysteryaboutanunknownpathogenwhichsickenedover1,000soldiersrighthereatCampBullisfrom1941-1944.Althoughavectorwasidentified,thepathogenwasneverproven.ThanksforyourcontinuedsupportofourAMEDDJournal.Iaskthatyouhelpmeinwelcomingthenewcommander,MGRussCzerw,withthenextedition. *DefenseOccupationalandEnvironmentalHealthReadinessSystemGlobalEmergingInfectionsSurveillanceandResponseSystemDoctrine,Organization,Training,Materiel,LeadershipandEducation,PersonnelandFacilities

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AprilJune20063Healthisanessentialelementofmilitaryreadiness,andpreventionisandalwayswillbethebestwaytohealth.Preventingdiseasesandconditionsthatthreatenthehealthofthewarfighterismoreoperationallysoundsinceitmaximizesavailablemanpower.ItismorebeneficialtotheSoldier,fromawell-beingperspective,tostayhealthyandavoidallthatthehospitalhastooffer,suchaslongwaitingroomtimes,diagnostics,andtreatment.Whenconsideringhealthcarecosts,bothshort-termandlong-term,preventionagainwinsout.Inanidealworld,themilitarywouldbeabletominimizediseaseandnonbattleinjuries(DNBI),throughpreventionandhealthpromotion,whileoptimizingtherestorativemedicineresourcesandapplyingthemtowardthosediseasesandconditionsthatarenotreadilypreventable,especiallycombatinjuries.Thisarticletakesabrieflookatmilitarypreventivemedicine,itsbackground,itscurrentstatus,andsomefutureconsiderationsforitsuseinimprovingthehealthofourwarfighters.Currently,inournation,approximately97%ofourmedicalcostsarefocusedontherestorativeaspectofhealthcareorfixingourmedicalproblems.Theother3%goestogovernmentalpublichealthexpenditures.1Militaryhealthexpensesaresimilar.Overthepastcentury,applyingtheappropriatelevelsofproactiveandresponsiveapproachestohealthcareseemstohaveworkedwell.Figure1showsthedramaticdecreaseinbothDNBIandbattleinjuries(BI),usinghospitalizationrates,duringvariouswarsandconflictsfromWorldWarII,throughOperationsEnduringFreedomandIraqiFreedom(OEF/OIF),includingOperationsDesertShieldandDesertStorm(ODS/S).TheratesforOperationsEnduringFreedomandIraqiFreedomareapproximatelyone-tenththatofWorldWarIIandtheKoreanConflict.However,theproportionofhospitalizationsforDNBIcomparedtoBIhasnotchangedsignificantlyandisactuallyalmostthesameorhighernowthanduringtheconflictsinKoreaandVietnam,asshowninFigure2.Inotherwords,whileArmymedicinehasdramaticallyimprovedoverall,theArmyisstillforcedtodedicateatremendousamountofresourcestoDNBI.TheArmymustdoabetterjobofprevention,ultimatelyrequiringalargerinvestmentthanthecurrent3%.Leadershipclearlyrecognizesthevalueofprevention.TherecentDepartmentofDefense(DoD)QuadrennialDefenseReviewReport(6February2006),states:ItistheDepartmentsgoaltohavealifetimerelationshipwiththeentireDepartmentofDefensefamilywhichmaximizesprevention,wellnessandpersonalchoices,andresponsibility.3TheDoDForceHealthProtectionCapstoneDocumentadds:Medicalassetsmustbeconfiguredtosupporthealthpromotion,healthPreventionistheBestWaytoHealthBGMichaelB.Cates,VC,USABGCatesistheCommandingGeneral,USArmyCenterforHealthPromotionandPreventiveMedicine, AberdeenProvingGround,Maryland,andtheFunctionalProponent,USArmyPreventiveMedicine. WWII Korea Vietnam ODS/S OEF/OIF Figure1.DecreaseinDNBIandBIduringUSconflicts. 2 **StatisticsforOEF/OIFwereobtainedfromtheUSTransportationCommandRegulating,CommandandControlEvacuationSystem(TRAC2ES)

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4ArmyMedicalDepartmentJournalhazardassessment,implementationofcountermeasuresandtheprovisionofessentialcareoftheinjuredandillintheaterandtheirrapidevacuationtodefinitivemedicalcareoutsideoftheaterofoperations.ForceHealthProtectionsupportsservicememberswithafullspectrumofhealthservicesthat(1)emphasizefitness,preparedness,andpreventivemedicine;(2)improvethemonitoringandsurveillanceofforcesinmilitaryoperations;(3)enhanceSoldiersandCommandersawarenessofhealththreatsbeforetheycanaffecttheforce;and(4)supportthehealthcareneedsofthefightingforcesandtheirfamiliesacrossthecontinuumofmedicalservices.4DoDDirective6200.4directsallmembersoftheActiveComponentsandtheselectedReserveComponentstobephysicallyandmentallyfit.Commanders,supervisors,individualservicemembers,andourhealthsystemhavebeengiventheresponsibilitytopromote,improve,conserve,andrestorethephysicalandmentalwellbeingofmembersoftheArmyForcesacrossthefullrangeofmilitaryactivitiesandoperations.5Specificverbiageregardingpreventionincludesitsrequirementsforallservicecomponentstopromoteandsustainahealthyandfitforce,preventinjuryandillness,[and]protecttheforcefromhealthhazards.5TheArmysbibleforthesepreventivemeasuresisArmyRegulation40-5,inwhichpreventivemedicineisdescribedastheanticipation,prediction,identification,surveillance,evaluation,prevention,andcontrolofdiseasesandinjuries.6Theregulationalsodelineates9majorfunctionalareasofsupporttomilitarypersonnelandtheirfamilies,ingarrisonanddeployedsettings,throughouttheworld.Whatiskeytothispublicationisthatresponsibilitiesforpreventivemedicinearegiventoawidevarietyofpeople,from3differentassistantsecretariesoftheArmy,to4primarydeputychiefsofstaff,TheSurgeonGeneral,majorcommands,regionalmedicalcommands,militarytreatmentfacilities,veterinarians,dentists,commandersatalllevels,installationcommanders,leaders,supervisors,andindividuals.6Dr.CraigLlewellyn,intheTextbookofMilitaryMedicine,7talksofthefar-reachingscopeofpreventivemedicinethroughouttheentiremilitaryforce.Hesaysthepromotionandpreservationofhealthandthepreventionofillnessandinjurycanrarelybeaccomplishedsolelythroughmedicalchannels.Whatwecallpreventivemedicineencompassesaverybroadspectrumofidentifying,assessing,andmitigatinghealthriskstoourpersonnel.BecausetheArmydeploysglobally,thosehealthrisksarespreadoutgeographicallyaswellasculturally.Intodaysworldofeasy,quicktransportation,onecountrysendemicdiseasescanbecomeanoutbreakinanothercountryspopulacealmostovernight.Publichealthinonecountryclearlyinfluencespublichealthinmanyothercountries.LaurieGarrett,inBetrayalofTrust,theCollapseofGlobalPublicHealth,agrees,sayingPublicHealthneedstobemustbeglobalprevention.8Withthestressesandoperationaltempoofourmilitarydeployments,itisimperativetorecognizethepotentialforexposurestounusualdiseasesandenvironmentalconditions.Also,lifestyle,nutrition,vehicles,weaponsandequipment,anddiseasevectorsallhavepotentialimpactontheSoldiershealth.Theproactiveapproachtowardminimizingthenegativeeffectsofthesehealthimpactsiscritical,notonlytotheindividualSoldiersbutalsototheirunits,ournation,andournationshealthcaresystem.Therearemultipleexamplesofpreventivemedicinesuccessesandfailuresthroughoutour Figure2.ProportionofhospitalizationsforDNBIandBIfromWWIItoOperationsEnduringFreedomandIraqiFreedom.2,**StatisticsforOEF/OIFwereobtainedfromtheUSTransportationCommandRegulating,CommandandControlEvacuationSystem(TRAC2ES) WWII Kore a Vietnam ODS/S OEF/OIF

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AprilJune20065militaryhistory.TheTextbookofMilitaryMedicinenamesmanysuccesses,includingyellowfeverinCubaandskindiseaseinVietnam.FailuresincludeBritishdealingswithtyphoidfeverintheSecondBoerWarandwithmalariainWorldWarI,andtheUSinvolvementwithheatandcoldinjuriesinWorldWarII.Itshouldbenotedthatallwereheavilyinfluencedbycommandemphasisonprevention,orthelackthereof.7Intodaysworld,thereareemergingorreemergingdiseases,suchastuberculosis,malaria,Acinetobacterinfections,leishmaniasis,andE.coliO157:H7infections;zoonoticdiseasesassociatedwiththeanimalsofthevariousregions;chronicdiseases,manyofwhicharerelatedtonutritionandotherlifestylechoices,suchasheartdisease,lungcancer,diabetes,etc;andillnessesrelatedtoexposuretotoxicindustrialchemicals,toxicindustrialmaterials,andpesticides.OurSoldiersdeploytolocationswiththreateningenvironmentalconditions,wherethesoil,air,water,andfood,inmanycases,posefardifferentthreatsthanmostareasoftheUS.Ourmilitarypersonneluseweaponry,vehicles,andotherequipmentthatpresentinherentriskstohearing,vision,andotherorganfunctions.Occupationalandenvironmentalexposuresgobeyondjustthedeployedsetting;thegarrisons,andtheirbuildings,roads,property,andwaterwayscanbedangerousaswell.Naturalandman-madedisastersonourownsoilandinothernationshavepresentedtheirownformofhealththreatsand,accordingly,theneedforpublichealth-relatedinterventions.TheArmyMedicalDepartment(AMEDD)preventivemedicineteamencompassesawiderangeofexpertiseinamyriadoflocations,withtheabilityandflexibilitytoprovidelocalsupportwhilemaintainingtheabilitytoprojectwhereverandwhenevertheneedarises.TheProponencyOfficeforPreventiveMedicineisresponsibleforpolicymakingandoversightintheOfficeofTheSurgeonGeneral.TheUSArmyCenterforHealthPromotionandPreventiveMedicineprovidestheoperationalfoundationforArmymilitarypublichealth,preventivemedicineandhealthpromotion.TheCenterisgloballypositioned,withcapabilitieswhichareeasilyprojectedwhenneeded.SmallerbutfullyfunctionalcapabilitiesarefoundwithindividualofficersandenlistedSoldiersassignedtobrigadecombatteams,preventivemedicinedetachmentsassignedtomedicalbrigadesandmedicalcommands,thetwoareamedicallaboratories,andthepreventivemedicinedepartmentsfoundattheArmymilitarytreatmentfacilities.Fromlocalinstallationsupport(suchasindustrialhygiene,immunizationsandoccupationalhealthservices)totheprojectedsupportprovidedbydeployedindividuals,detachments,andSpecialMedicalAugmentationResponseTeamsPreventiveMedicinetoIraqandAfghanistan,theCentersentireteamdoesalotwithrelativelyfewresources.AfterHurricaneKatrinahitthesouthernUScoast,militarypreventivemedicinepersonnelweredeployedquickly.WhentheearthquakehitPakistanin2005andtheUSArmysentmedicalpersonneltohelp,preventivemedicineexpertswereanimportantandvisiblepartofthehumanitarianassistanceoperation.WhentherewerepotentialoutbreaksofhepatitisCinElPaso,meningococcaldiseaseinEurope,ortuberculosisinAfghanistan,preventivemedicineexpertswereonthescenetodeterminethecauseofthediseaseandthepotentialhealththreatstopersonnel.Healthpromotioninitiativescontinuetobeanintegralpartofpreventivemedicinetodrivedowninjuries,tobaccouse,andalcoholabusewhileenhancingnutritionandoverallfitness.Wearepartofthecontinuingsurveillanceofoccupationalandenvironmentalhealththreatstoourmilitarypersonnel,bothindeployedandgarrisonsettings,providingbroad-ranging,veryeffective,globallycommittedpreventivemedicinecapabilities,withconstrainedresources.Atthenationallevel,therehasbeenarenewedfocusonhealthpromotionandprevention,asevidencedbytheHealthyPeople2010initiativebytheDepartmentofHealthandHumanServices.Thisinitiativehassetouttoidentifythemostsignificantpreventablethreatstoourhealthandtoestablishnationalgoalstoreducethosethreats.Certainstatisticsjustifythiseffort:Heartdiseaseandstrokeaccountfor40%ofallUSdeathseachyear,64%ofUSadultsareobeseoroverweight,and31millionhaveasthma.9Diabetesnowaffects20.8millionAmericans,7%ofourpopulationanda6.3%increasesince2002.10Likethemilitary,theUSasawholespendsaninordinateamountonhealthcare15%ofthegrossdomesticproductin2003,thehighestofanymembercountryoftheOrganisationforEconomicCooperationandDevelopment(OECD).TheUSspendsover$5,600percapitaontotalhealthcare,morethantwicetheOECDaverage;despitethat,thereareindicationswearenohealthierthanotherdevelopedcountries.11

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6ArmyMedicalDepartmentJournalAstheArmymovesforward,ourdeploymentsarelongerandmoredispersedthroughouttheworld.Therefore,environmentalexposureswillincreaseindiversityaswellasintensity.TheAMEDDpreventivemedicineteamsmustkeepuptheirvigilanceofmedicalandenvironmentalsurveillance,communicatingquicklyandeffectivelywhennecessarytocorrectdeficienciesandhaveapositiveimpactonthehealthofindividualSoldiersorunits.Healthpromotioneffortsmustcontinuetobeaggressive.Similartoourciviliancounterparts,themilitaryhastocontendwithmanyoftheheathrisksassociatedwithlifestylechoices,suchastobaccouse,poornutrition,andalcoholabuse.AmongmaleSoldiersage18to25,48%usetobacco.Over27%ofourmilitarypersonnel,age26to34,areoverweight(withbodymassindexastheindicator),andover40%ofourSoldiersengageinbingedrinking(thatis,5ormoredrinksatoneoccasionatleastoncein30days).12Thesestatisticspresentshort-termandlong-termimplications,impactingnotonlyindividualsbutalsoentireunits,ourmilitaryasawhole,andourmilitaryhealthcaresystem.Inthefuture,medicaltechnologywillhelpusdoabetterjobofidentifying,assessing,andmitigatinghealthrisks,and,hopefully,leadersatalllevelswillbecomeactivelyengagedinpromotingbetterpreventionandtheoverallmedicalreadinessoftheirSoldiers.Justaspreventivemaintenanceisacrucialaspectofthelogisticscommunity,drasticallyimprovingtheavailability,workability,anddurabilityofourequipmentandvehicles,preventivemedicineiscrucialtoourmostimportantresourceourpeople.Fixingsomethingmuchmoreinefficientthansustaining,maintainingandimprovingit;thisdirectlyappliestoourhealth.MaintainingandevenimprovingaSoldiershealthisamuchmoreappropriate,wiseruseofresourcesthanwaitinguntilthatSoldierbecomessickorishospitalized.Themorewepreventdiseasesandimprovepoorenvironmentalconditions,themoreresourceswillbeavailabletoapplytothosethingswecannotprevent.Preventioneffortshavebeenandstillareeffective,invaluablepiecesofthemedicalhealthsystem.Andwhilethereiscontinuingandgrowingemphasisonproactiveapproachestohealthintodayssocietyandmilitary,wemustallstrivetowardtranslatingthatintoreal,evengreaterlong-terminvestmentsinthefuturehealthofourpersonnel.REFERENCES1.HonorePA,AmyBW.Publichealthfinance:advancingafieldofstudythroughpublichealthsystemsresearch.JPublicHealthManagePract.2005;11(6):571-573.2.JonesBH,PerottaDM,Canham-ChervakML,NeeMA,BrundageJF.Injuriesinthemilitary:areviewandcommentaryfocusedonprevention.AmJPrevMed.2000;18(3Suppl):71-84.3.QuadrennialDefenseReviewReport.Washington,DC:USDeptofDefense.February6,2006.Availableat:http://www.defenselink.mil/pubs/pdfs/QDR20060203.pdf.4.ForceHealthProtectionCapstoneDocument.FallsChurch,VA:USDeptofDefense,OfficeoftheAssistantSecretaryofDefense(HealthAffairs),TRICAREManagementActivity;2004.Availableat:http://www.ha.osd.mil/forcehealth/library/main.html.5.DoDDirective6200.4:ForceHealthProtection(FHP).Washington,DC:USDeptofDefense;October9,1994.6.ArmyRegulation40-5:PreventiveMedicine.Washington,DC:USDeptoftheArmy;22July2005.7.TextbookofMilitaryMedicine:MilitaryPreventiveMedicine,MobilizationandDeployment.Washington,DC:USDeptoftheArmy,OfficeofTheSurgeonGeneral,BordenInstitute;2003.8.GarrettL.BetrayalofTrust:TheCollapseofGlobalPublicHealth.1sted.NewYork,NY:Hyperion;2000.9.HealthyPeople2010:TheCornerstoneforPrevention.Washington,DC:USDeptofHealthandHumanServices,OfficeofDiseasePreventionandHealthPromotion;2005.Availableat:http://www.healthypeople.gov/document.10.NationalDiabetesFactSheet.Washington,DC:USDeptofHealthandHumanServices,CentersforDiseaseControlandPrevention;2005.Availableathttp://www.cdc.gov/Diabetes/pubs/estimates05.htm.11.OECDHealthData2005:HowDoestheUnitedStatesCompare.OrganisationforEconomicCooperationandDevelopment;June2005.Availableathttp://www.oecd.org/dataoecd/15/23/34970246.pdf.12.BrayR,HouraniL,RaeK,etal.2002DoDSurveyofHealthRelatedBehaviorAmongMilitaryPersonnel:FinalReport.ResearchTrianglePark,NC:USDeptofDefense,ResearchTriangleInstitute;2003.

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AprilJune20067TheArmyPreventiveMedicineResidencyisnowofficially47yearsold.Firmlyestablished,accredited,andrespected,itsgraduatessitfortheirboardswiththeirciviliancontemporaries,becomeFellowsoftheAmericanCollegeofPreventiveMedicine,andpursuecareersinpublichealthpractice,education,administration,andresearch,thesameastheirciviliancolleagues.Itwasnotalwaysthecase.Thedevelopmentofcivilianpreventivemedicine/publichealtheducationandacceptanceprogressedoverarockyroadofprofessionalanimositywhileitsmilitarycounterpart,byvirtueofnecessity,evolvedonasmootherpath.Althoughpreventivemedicine,asanaccreditedresidency,wasalatecomertoArmygraduatemedicaleducation,asacontinuous,systematiccourseofinstruction,itistheoldestpostgraduatemedicaltrainingprograminthemilitary.Thisarticletracestheevolutionofthattrainingandhowitparalleledcivilianpublichealtheducation.TheideaofagraduateArmymedicalschoolwasfirstproposedbySurgeonGeneralWilliamA.Hammondin1862.Aprogressivethinker,hehadalreadycreatedanArmymuseumforpathologicalresearchandorderedthepreparationofamedicalhistoryofthewaroftherebellion.1(pp179-180)Hammondfelttherewasabetterwayforphysicianstolearntheartofmilitarymedicineandsurgerythanbytrialanderrorwhileoncampaign.HeenvisionedanArmymedicalschoolthatwould,inMajorJohnBrintonswords,teach[thesurgeons]howsoldiersshouldbelookedafterinhealth,onmarches,incamp,howtheyshouldbetreatedwhensickorwounded,howcaredforinhospitalsorinthefield,andhowproperlytransported.1(pp257-258)Therewaslittlemoneytosupportthiseducationalventure.Therefore,HammondestablishedaclassroomandacoupleoflaboratoriesintheroomsbeneaththemainhalloftheArmyMedicalMuseumwhichwashousedintheoldRiggsBankbuildinginWashington.OnlySecretaryofWarEdwinM.Stantonsapprovalwasneededtobeginclassesinthefallof1863.Regrettably,HammondhadclashedwiththeSecretaryofWarearlyinhistenureandhadbeenremovedasSurgeonGeneraltheprevioussummer.WhenActingSurgeonGeneralJosephK.BarnesshowedStantontheschool,theSecretaryofWarinquired,Aretheselecturestobegivenintheevenings?Theactingsurgeongeneralrepliedintheaffirmative,towhichStantonthunderedTheywillgotothetheatreandneglecttheirduties.Itshantbe!1(p259)Thisseedofanideadidnotdie,butratherwentintodormancywaitingforanewchampionandamoreagreeabletime.Thattimecameinthespringof1893.TheGildedAgewasrecedingandthetideoftheProgressiveErawasbeginningtorollin.Onthattidecameaverydifferentageassocial,economic,technological,andscientificchangesindeliblyalteredtheAmericanwayoflife.Bacteriology,developedbyKoch,Pasteur,andothers,andthenascentscienceofimmunologywereestablishingafoundationforpublichealthpracticethatwasbeingeffectivelyappliedbyinnovativephysiciansinstateandmetropolitanpublichealthdepartments.2IntheArmyMedicalDepartment,GeorgeMillerSternbergwasselectedasSurgeonGeneralover10seniorofficers.Acareerofficer,experiencedmilitarycampaigner,andmedicaleducator,hewasaninternationallyknownandrespectedbacteriologistandsanitarian.3(pp6,13,60,94),4,5Tohissupportershewasthepersonificationofthisnewmedicalscience.OnJune24,1893,justalittleoverthreeweeksfromthetimehetookoffice,SternbergresurrectedTheEvolutionofPublicHealthEducationintheUSArmy,1893-1966COLStephenC.Craig,MC,USA BGGeorgeSternbergArmySurgeonGeneral18931902

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8ArmyMedicalDepartmentJournalHammondsidea,byestablishingtheArmyMedicalSchool(AMS)inavailablespaceattheArmyMedicalMuseumandLibrary.ThepermanentfacultywascomposedofmedicalofficersstationedinWashington,DC.COLCharlesH.Aldenbecamepresidentofthefacultyandlecturedonthedutiesofmedicalofficers.COLWilliamH.Forwoodtaughtmilitarysurgery,andmilitaryhygienewastaughtbyMAJJohnS.Billings.MAJCharlesSmartlecturedonmilitarymedicineanddirectedthechemicallaboratory,andCPTWalterReedlecturedinbacteriologyandwassecretaryofthefaculty.CPTJulianM.CabellwasbroughtintoassistForwoodandteachHospitalCorpsdrillonSaturdaysatFortMyer,Virginia.6(pp21,23)InanotesenttotheSecretaryofWar,Sternbergwasveryclearaboutthepurposeoftheschool:Thereisnoneedtoteachmedicineandsurgerytograduatesofourmedicalcolleges,buttherearecertaindutiesofanArmymedicalofficerwhichthecollegecoursehasnotpreparedthemwhicharemoreimportantthantheclinicaltreatmentofindividualcasesofdiseaseandinjury.Aspecialeducationisneedfultoprepareamilitarymantoundertaketheprotectionofthepublichealth.Thecourseatthearmymedicalschoolwillpreparehimtocopewiththequestionsofpracticalsanitationthatwillbepresentedtohimateveryturninhismilitarycareer.7Indeed,Sternbergconsideredpreventivemedicineandpublichealthasthefoundationformilitarymedicalpractice,andteachingtheseprinciplestobetheprimaryfunctionoftheschool.Healsosoughttopreparethemfortheirrolesasmilitaryofficersandmodernphysicians.Ifmedicalofficersweretobeeffectiveingarrisonandonthebattlefield,itwasimperativethattheylearntofunctionandcommunicateinamilitaryframework.Sternbergexpectedanumberofthesestudentstorisetocommandhospitalsinthefuturewheresuccessdependeduponathoroughunderstandingofhospitaladministration,logistics,andmilitarylaw.Furthermore,themodernmedicalofficerhadaresponsibilitytomaintaineducationalcurrency,pursuepracticalresearchateveryopportunity,andsharehisresultswithhiscolleagues.8Coursesinmilitarysurgery,medicine,andhygiene,thedutiesofmedicalofficersinwarandpeace,militarylaw,andmedicaljurisprudenceweredeveloped.Laboratoryinstructioninsanitarymicroscopy,pathologicalhistology,bacteriology,andurinologywasprovided.6(pp26-29,32-33)Establishingamodernprofessionalcommitmenttolifelonglearning,however,wouldonlybeginwithclassroomandlaboratoryinstructionandmentorship.Itsrealizationwoulddependuponanofficersinterestinresearchandacontinuingexamplefromtheschool.SternbergenlargedandmodernizedtheMedicalMuseumLaboratory,notonlyforthebenefitofthestudents,butalsotoexpanditsmissiontoincludemoderninvestigativeresearch.IntheexecutionofthisendeavorhereliedheavilyuponCPTWalterReedandDr.JamesCarroll.Reed,whobecameSternbergsalteregointhelaboratoryandonnumerousfieldassignments,andCarrollbeganconductingexperimentsintothevalueofcresolasadisinfectant,smallpox,and,later,yellowfever.Epidemiologicalfieldinvestigationswereconductedasrequired.9-13Theschoolgotofftoafinestart,graduatingitsfirstclassin1894.Itgraduatedthreemoreclasses,andbeganawardingtheHoffmedalforacademicexcellencein1898,beforetheWarwithSpainclosedtheschoolforthreeyears.6(p24),14,15Whenthewarended,Americahadanewempire,rifewithendemic FirstArmyMedicalSchoolGraduatingClass,1894.Standinglefttoright:TSBratton,ASPorter,DCHoward,WHWilson;Seated:WWQuintonArmyMedicalMuseumandLibraryat7thandBStreets,SW,WashingtonDC.BGSternbergestablishedtheArmyMedicalSchoolinthisbuildinginJune1893.

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AprilJune20069diseases,inwhichSternbergsawnotonlychallengesfortheMedicalDepartment,butalsoopportunitiesforittoadvancemedicalscience.PublichealthwouldplayamajorandinterdependentroleinaccomplishingthenationbuildinggoalsoftheMcKinleyadministration.Boardsofhealthwerecreatedwhichdirectedsanitationandlargescalesmallpoximmunizationprograms.InNovember1899,AssistantSurgeonGeneralBaileyK.Ashford,withonlybasiclaboratoryequipmentandtechniquesacquiredattheAMS,demonstratedthatPuertoRicananemiawasduetothehookworm,Necatoramericanus.*InJanuary1900SternbergsponsoredaBoardfortheStudyofTropicalDiseasesinthePhilippines.16(p531)TheorganizationalformatoftheformalboardwasknownandunderstoodbytheArmy,andSternberghadappliedthisformattothetyphoidfeverinvestigationconductedbyReed,VictorC.Vaughn,andEdwardO.Shakespeareduringthewar.13SternbergtoldSecretaryofWarElihuRootthatItwasmydesirethatthis[TropicalDisease]boardshouldbegivenalltheappliancesandassistancenecessaryforconductingtheirresearchesandeveryopportunityforobtainingaccesstocasesandmakingautopsies,etc.InmyletterofinstructiontothechiefsurgeonIstatedthatthemembersoftheboardwhilepursuingtheirgeneralinvestigationscouldmakebloodexaminationsandbacteriologicalresearchesforthepurposeofclinicaldiagnosisaswellaswithaviewtothepromotionofourknowledgeofinfectiousdisease.16(p531)SternbergalsocreatedtheYellowFeverBoardinCubaafewmonthslaterwithasimilarintent.16(p532)Whiletheseboardsfocusedondiseasesmostcommonlyencounteredbysoldiers,andcertainlyprovidedimmediatediagnosticassistancetoclinicians,hisinstructionsdefinedalarger,moreautonomousandpermanentgoal:theestablishmentofaproductive,enduringresearchcapabilityintheUSArmyMedicalDepartment.BythetimeSternbergretiredinJune1902,themedicalschool,laboratory,andtropicaldiseaseboardsprovidedafirmfoundationfortheintegrationandmanagementofpublichealtheducationandresearchsciencewithintheArmy.3(p237)Hehadproducedthefirstpostgraduate,schoolhousetrainedpreventivemedicineofficers.Academicmotivationamongthestudentofficerswasaproblem,however.Reedrecognizedthisfactandcommentedaboutthefirstclass:Althoughnomemberoftheclasshasexhibitedanyspecialenthusiasmfortheworkpursuedinthislaboratory,allhaveacquittedthemselvestomysatisfaction.6(p31)COLAldenidentifiedtherootcauseforthislackofincentivewhenhestatedTherankofthestudentofficersisalreadyfixedbeforetheyentertheschool,andisnotaffectedbytheirproficiencyattheschool.Itisverydesirablethatthefuturerankofthosestudentofficerswhohaveenteredtheservicejustbeforethesessionshouldbedeterminedbythecombinedresultsoftheexaminationforentranceintothecorpsandtheirworkattheschool.6(p24)Between1902and1907,ArmyMedicalServicecoursesweremademorerobust.Theacademicsessionwaslengthenedtoeightmonthsduration,militarymedicinebecamemilitaryandtropicalmedicine,andthreenewcourseswereadded:operativesurgery,ophthalmology,optometry,andradiology.17(p12),18(p121)Togainmorecontrolovermedicalofficercandidates,commissionswerenotawardeduntilaftertheofficerhadsuccessfullycompletedallcourseswithascoreof80%orbetter.17(p13),19Classsize,however,wasonthedecline.Inhisannualreportfor1907,SurgeonGeneralRobertM.OReillycommentedObviously,thearmymedicalservicehaslostmuchofitsattractionforthebrightyounggraduatesfromourbestmedicalschools,andunlessaremedyissoonsupplied,bysuitablelegislation,itwillbeimpossibletofillvacanciesinthemedicalcorpswithoutloweringthepresentstandardofexamination,aresortwhich,ifadopted,wouldleaveusdistinctlyoutclassedbythemedicalcorpsofthearmiesofallothercivilizedcountries.18(p122)ThepaywaslowandpromotionswereslowintheMedicalDepartment.OReillywasgrapplingwithaperennialproblemthatSternberghadneversolved,andhissuccessorsstillworryaboutonaregularbasishowtoobtainandkeepmedicalofficersinuniform.SecretaryofWarRootandhissuccessor,WilliamTaft,agreedwiththesurgeongeneralthatsufficientnumbersofmedicalofficershadtobetrainedinpeacetimetobeavailableinacrisis.In1904,OReillydraftedabilltoincreasetheefficiencyandenlargetheMedicalDepartment.AlthoughcongressdidnotactonituntilApril1908,whentheydid,anumberofsignificantchangesoccurred.Thelegislationcreated123newmedicalofficervacancies,relievedslow*References16(pp610,681,699-700,701,723-724)

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10ArmyMedicalDepartmentJournalpromotionsbyrequiringexaminationsforpromotionfrommajortolieutenantcolonel,increasedpay,allowedphysicianstomoonlightonlyifitdidnotinterferewithArmydutiesnorrequireanoff-postoffice,andcreatedtheMedicalReserveCorps,theArmysfirstreservecorps.20(pp321-22)TheAMSnotedanimmediateincreaseinclasssizeandtwoyearslatermovedintolargerquartersintheoldBuildersExchangeon13thStreet,NW.21(p133),22(p132)Inthedecadefrom1908to1917,militarymedicaleducationandresearch,andtheArmyMedicalServiceoverallbegantheslowmetamorphosisintotheformrecognizedtodayastheWalterReedArmyInstituteofResearch.FrederickRussell,whodevelopedaneffectivetyphoidvaccinein1908thatwastestedonthestaffandstudentsandmademandatoryintheArmyandNavyin1911,servedonthefaculty,asdidPercyAshburnandCharlesCraig.20(p348),22(p131),23AshburnandCraigwerefreshfromthePhilippineswheretheyhadconductedoriginalresearchonplague,dengue,andmalaria.EdwardVedder,whosolvedtheproblemofinfantileberi-beriinthoseislandsbysupplementingbreastmilkwithanextractofricepolishings,taughtbacteriology.24,25(p162)CarlDarnall,whodevelopedapracticalfieldapparatusforchlorinatingwaterin1910,taughtchemistry.22(p131)WilliamLyster,whogaveuscleanwaterusingcalciumhypocholoriteinacanvasbagin1913,servedforatimeasthemilitaryhygieneinstructor.25(p162)TheseyoungofficerswereSternbergsdisciples,dedicatedtomilitarymedicaleducation,research,andmentoring.ValeryHavardandPercyAshburneachpublishedhandbooksonmilitaryhygienein1909toupdateMunsonscomprehensiveworkfrom1901.In1915thefirstpostgraduatecourseinpreventivemedicinewasofferedtomoreseniorofficers.*TotheHoffMedalwasaddedtheSternbergMedalforexcellenceinbacteriologyandserumtherapy.Sternbergawardedthefirstonehimselfin1913.28However,thecommandantoftheschool,COLWilliamH.Arthur,lamentedin1916thattoomuchtimeisgivenuptolaboratoryworkandnotenoughattentionpaidtosanitarytactics.Whilethelaboratoryworkisveryimportant,itisnotstrictlymilitary,andthestudentshavenoopportunityoflearningtocareforthemselvesincamp,thedetailsofcampsanitation,andthegeneraldutiesofmedicalofficersinthefield.27(p200)However,thistoowaspartoftheongoingmetamorphosis.ArmyInspectorGeneralErnestGarlingtoncommentedin1910thatmedicalofficersrequiredmoretrainingincampaignwork.AyearlatertheFieldServiceandCorrespondenceSchoolforMedicalOfficerswascreatedatFortLeavenworthunderthedirectionofMAJEdwardMunsontoinstructRegularandNationalGuardphysiciansinstaff,field,andadministrativeduties.20(p324)ButtherewasnolongeranyroomattheAMSforsuchtraining.Theschoolmovedonceagainin1917,thistimetoofficesvacatedbytheDepartmentofCommerceonLouisianaAvenue,justintimetoabsorbthemassiveinfluxofphysicianswhowouldputtheirskillstoimmediateusewiththeAmericanExpeditionaryForcesinFrance,andavarietyofotherwartimeresponsibilities.Trainingcoursesexpandedandweresetupatavarietyofposts.Threehundredofficersweretrainedinfivesessionsandover200otherreserveofficersreceivedrefreshercoursesandpreparationforoverseasmovement.Largenumbersofenlistedlaboratoryandx-raytechniciansweretrained,anorthopedicsectionwasestablishedtogiveinstructioninorthopedictheoryandpractice,and750physicalexaminationsforappointmentandpromotionintheReserveCorpswereperformedeachmonth.Eighteenmilliondosesoftyphoidvaccinewereproducedandshipped,andoilsuspension*References21(p136),26(p171),28(p198) OfficesvacatedbytheDepartmentofCommerceonLouisianaAvenuebecamethehomeoftheArmyMedicalSchoolin1917

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AprilJune200611vaccinesfordysentery,pneumococcalpneumonia,meningitis,streptococcalinfections,andcholeraweredevelopedandtestedinthelaboratory.29,30Inthelatefallof1917,SurgeonGeneralWilliamC.Gorgasledateam,consistingofCOLDeaneHowardandreserveofficersCOLWilliamWelchandMAJVictorVaughn,onaninspectiontourofanumberofsouthernandwesternmobilizationandtrainingcamps.Therewasagrowingconcernthattheamountofmeasles,mumps,meningitis,andpneumoniaatthesecampswasexcessive.TheydeterminedthattheSanitaryInspectorsatthesecampsneededassistanceintheformoftrainedepidemiologistswhowouldconductsurveillance,evaluatetheexaminationsofincomingandoutgoingsoldiers,recommendcontrolmeasures,educatemedicalofficersoncommunicablediseases,andreportroutinelytotheSurgeonGeneralsOffice.GorgasissuedorderstothiseffectinJanuary1918.31Epidemiologistsbecameanintegralpartoftherobustpreventivemedicineteamsthatservedstateside,particularlyduringtheInfluenzaPandemic,inEuropeduringthewar,andinthepost-waroccupationoftheRhineland.Civilianpublichealtheducationwasalsodevelopingintheearlypartofthetwentiethcentury,anditsevolutionprovidessomeinterestingcontraststoeventsoccurringintheArmy.AccordingtoWelch,SternberghadcreatedAmericasfirstschoolofpublichealthattheAMS,32butitisalittleknownfactthatSternbergalsoassistedincreatingoneofthefirstcivilianschoolsofpublichealth,wherehealsoservedasfacultypresident.AjointventureoftheGeorgetownandColumbianUniversityMedicaldepartments,theWashingtonPostGraduateMedicalSchoolopeneditsdoorsinJanuary1903.Itgavespecialattentiontopreventivemedicine,tropicaldiseases,andlaboratoryworkinbacteriologyandsanitarychemistry,asthesesubjectswouldbeextremelyvaluabletogeneralpractitioners,specialists,andhealthofficersinthegovernmentservice.Thirteenmonthslater,thePresidentandUniversityCouncilofColumbianUniversity,soontobeGeorgeWashingtonUniversity,presentedapetitiontotheBoardofTrusteesfortheestablishmentofagraduateDepartmentofPublicHealthwhichofferedMastersandDoctorateofPublicHealthdegrees.SternbergacceptedtheDeanschairforthedepartmentandcontinuedtoteachclassesinhygieneandpreventivemedicine.33,34,35,36Theprominentgrowthofbacteriologyandimmunology,emergenceofstateboardsofhealth,thecontinuingurbanizationofthecountryandresultingsanitaryproblems,andtheneedforproperlytrainedprofessionalstodealwiththeseissueswasapowerfulstimulusfortheestablishmentofotherpostgraduateprograms.In1906WilliamSedgwickwasteachingprinciplesofpublichealthpracticeattheMassachusettsInstituteofTechnology.*By1912hisprogramhadjoinedwiththatofMiltonRosenauatHarvard.TheirSchoolforHealthOfficersofferedaCertificateinPublicHealthandadoctorate.PublichealthtrainingprogramswereestablishedbyVictorC.VaughnattheUniversityofMichiganin1912,AlexanderAbbottattheUniversityofPennsylvaniain1914,C.E-A.WinslowatYalethefollowingyear,andaSchoolofPublicHealthopenedatJohnsHopkinsUniversityin1918.However,standardcoursework,suchassanitaryengineeringandlegislation,sanitarysurveys,andinspectionsofconsumableanimalproducts,tookthephysicianoutsidetherealmoftraditionalmedicaleducationandpractice.Thepublichealthdoctoralsohadtoembraceabroadrangeofco-equalcolleaguesaspublichealthprofessionals.Sedgwicksprogrambeganwithnonphysicians,andbythetimeHopkinsopened,applicantsincludedsanitaryengineers,chemists,epidemiologists,nurses,andsocialworkers.37(pp148-149)Astheschoolsmatured,theiradvocateshopedthatpublichealthandpreventivemedicinewouldbecomepartofclinicaltraininginallmedicalschools.37(p183)However,manyphysiciansweresimplynotinterestedinpublichealthtraining,andphysiciandominanceinthefielddiminishedduringtheinterwaryears.PublicHealthOfficerjobswerelowpaying,lackedtheexcitementofcurativemedicine,werefrequentlygiventophysicianswithoutspecializedtraining,andthereforeofferedlittleincentiveforbrightyoungphysicians.37(pp184,189-190)Furthermore,thiswastheerawhenspecializationbegantogrowresidencyprogramsdoubledbetween1934and1940andwiththatgrowthcamethecomplexitiesofstandardizedtraining,licensing,andregulation.Generalpractitionerssawtheirautonomyandscopeofpracticediminishwiththearrivalofeachnewspecialist.Whenthatspecialistworkedforthepublichealthhealsoborethestigmaofstatemedicine.Governmentalinfluenceinthedeliveryofhealthcare,suchastheSheppard-TownerActof1921whichgavefederalmoniestostatesformotherandchildhealthmaintenance,threatenedto*References37(pp150-183),38(p194) References37(pp151-152),38(p253),39References40(pp149-153,155,258)

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12ArmyMedicalDepartmentJournalaltertraditionalfee-for-servicepracticesandphysicianautonomy.*PublicHealthDepartmenteffortstocontrolinfectiousdiseaseswereinterpretedbylocalpractitionersasunfairstatecompetition,andtheprofessionofpublichealthbecameincreasinglyatoddswithclinicalmedicine.Whiletheindifferent,andoftenblatantlyhostile,establishedmedicalcommunitypushedpreventivemedicinefartherawayfromtheclinicalrealmandprecludeditsincorporationintomedicalschoolandhospitaltraining,theArmyMedicalDepartment(AMEDD)pursuedadifferentapproach.InSeptember1923,theArmyMedicalService(AMS)beganmovingintoBuilding40ontheWalterReedcampus,andbecamepartoftheArmyMedicalCenterwhichwasestablishedthesamemonth.41(p247)ConsistingofWalterReedGeneralHospital,whichhadopenedin1909,andtheArmyMedical,Nursing,Veterinary,andDentalSchools,themedicalcenterrepresentedtheculminationofArmyMedicalDepartmenteffortstosecuresuitablefacilitiesforfurtheringthemedicaleducationsystemoftheArmyinthenationalcapitalarea.Themedicalcenterconceptimprovedandstrengthenedtherelationshipofthemedicalschoolwiththeotherschoolsandthehospital.41(p246)Aconsiderableamountofhospitalradiographicandlaboratoryworkwasdoneattheschool,moretimewasgiventoclinicalwork,andclosercontactwasmaintainedwithhospitalcases.Directorsattheschoolweregivenconsultanciesinthehospitalandhouseofficersweremadeinstructorsintheschool.Inadditiontothebasicpreventivemedicinecourseandpostgraduateroentgenologycourse,theschoolnowoffereda14weekpostgraduatesessioninpreventivemedicinewhichincludedinstructioninbacteriology,personalhygiene,protozoology,immunology,epidemiology,helminthology,entomology,chemistry,andvitalstatistics.41(pp247-48),42In1928preventivemedicineachieveddepartmentalstatuswhenitbecamepartoftheDepartmentofLaboratories,PreventiveMedicine,andClinicalPathology.43Threeyearslater,twonewwingswereaddedtotheschooltoaccommodateitsgrowth.FouryearsafterthattheArmyMedical,Dental,andVeterinarySchools(theArmySchoolofNursinghadclosedinJanuary1933)wererenamedtheMedicalDepartmentProfessionalServiceSchool.44In1936SurgeonGeneralCharlesReynoldsrecognizedtheneedforastrongpreventivemedicineserviceinwartime.45(p177)AmemberoftheAMSfaculty30yearsbeforeandDeputyChiefSurgeonintheAmericanExpeditionaryForcesin1917,Reynoldshadakeenappreciationforthespecialty,andcommentedThemostvaluablecontributionsoftheMedicalDepartmentoftheArmyhavebeeninthefieldofpreventivemedicine.Thedividendsfromintelligentserviceinthefuturewillbenoless.45(p179)TodirectthePreventiveMedicineService,laterthePreventiveMedicineDivision,intheOfficeoftheSurgeonGeneral,hebroughtinCOLJamesS.Simmons.Oneofthefewofficerstoholdadoctorateinpublichealth,SimmonshadadistinguishedcareerininfectiousdiseaseresearchattheAMS,hadbeenpresidentofthemedicalresearchboardsinthePhilippinesandCanalZone,andwasanacknowledgedauthorityonmalaria.45(pp178-79)Inlate1939theUSbegantomobilizeforwar.Simmons,withonlyasmallcadreoftrainedpublichealthofficers,successfullyco-optedawiderangeofnationalresources,suchastheUSPublicHealthService,NationalResearchCouncil,andRockefellerFoundation,totrainthelargenumbersofphysiciansrequiredtopreservethehealthofanexpandedArmy.TheBoardfortheInvestigationandControlofInfluenzaandOtherEpidemicDiseasesintheArmy,establishedin1940andnowknownastheArmedForcesEpidemiologicalBoard,consistedofdistinguishedcivilianscientistsandMedicalDepartmentofficerswhoworkedincoordinationwiththeirrespectiveresearchfacilitiestosolvemajordiseaseproblemsaffectingtheArmy.Shortcoursesin*References37(p185),40(pp136-137,143)

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AprilJune200613sanitationandhygiene,whichtaughtmethodstoprecludeandinterruptrespiratory,venereal,andvector-bornediseases,weredevelopedastheyhadbeenin191718.Forofficersassignedtothetropicsandadjacentareas,theAMSinitiatedafour-week,malariaanddysenteryintensivecoursethatwaslengthenedtoeightweeksafterPearlHarbor.Althoughclassesbeganwith20to30officers,by1943eachsessionwasgraduating100officers.*Naturally,Simmonsrecognizedtheschoolcouldnotpossiblyeducatethenearly40,000Armymedicalofficersondutythatyear.WiththeaidoftheNationalResearchCouncil,hebeganbuildingapooloftrainedcivilianphysiciansbyhavingmedicalschoolsandteachinghospitalsprovidetropicalmedicinecoursestotheirseniorstudentsandinterns.47(pp11-14)Fieldtraininginmalariacontrolalsoreceivedcloseattention.InstructionwasconductedforselectedmedicalandsanitaryofficersinFloridaandalongthePan-AmericanHighwaybeingconstructedbyArmyEngineersfromPanamatoMexico.47(pp19-20)MalariawasprovingtobethebaneofcommandersinthesouthwestPacific.ForcesonGuadalcanalandtheBunaIslandsweresaturatedwithit.WhenGeneralMacArthurwasbriefedaftertheBunafightinJanuary1943that72%ofthecombinedforcewassick60%withmalariahecommentedtohismalariaconsultant,Doctor,thiswillbealongwarifforeverydivisionIhavefacingtheenemy,Imustcountonaseconddivisioninhospitalwithmalariaandathirddivisionconvalescingfromthisdebilitatingdisease.46(p2)InresponsetothemalariacrisisinthePacific,anArmySchoolofMalariologywasestablishedintheCanalZonetoprovidetrainingandadvancedinstructiontomedicalandsanitaryofficersandenlistedtechnicians,whomadeupspecialvectorcontrolteams.Alloftheseefforts,plusintensivetroopeducationandtheintroductionofAtabrineformalariachemoprophylaxis,broughtmalariaundercontrolinendemicareasduringthelastyearofthewar.47(pp21-25)By1945,thestrifebetweenpublichealthandclinicalmedicineoftheinterwaryearshadleftAmericawithtoofewtrainedpublichealthphysicians.48Determinedtoenlargetheirranks,leadersinpublichealthrecognizedandembracedthefactthatmedicalspecializationwastheonlywaytoexpandandgaincredibilityandacceptancewithintheprofession,whethercivilianormilitary.Duringthewarthegovernment,bygivinghigherrankandpayandlargerresponsibilitiestocertifiedspecialists,hadacknowledgedtheirsuperiorprofessionalstatus.40(pp279-280),49Whilethenumberofresidenciescontinuedtogrowthroughthe1940s,specialtyboardssoughtqualitycontrolbyrequiringatleastthreeyearsofpost-internshiptrainingandworkinginconjunctionwiththeresidencyinspectionsystemconductedbytheAmericanMedicalAssociationCouncilonMedicalEducation.40(p258)Toachievetheprofessionalstatusandprestigesolongdesired,theAmericanPublicHealthAssociationandtheAmericanMedicalAssociation(AMA)cametogetherin1948tocreatetheAmericanBoardofPreventiveMedicineandPublicHealthandbegintodefinetrainingstandardsandestablishresidencyprograms.40(p330)Aftercompletionofinternship,preventivemedicineresidentscompletedoneyearofgraduatestudyleadingtoamastersinpublichealthfollowedbytwoyearsofacademicandfieldtraininginanapprovedpreventivemedicineprogram.50By1951,publichealthdepartmentsin12stateshadapprovedpubichealthresidencyprogramsofthreeyearsduration.51Althoughoriginallyintendedtogeneratepublichealthspecialists,subspecialtiesinthefieldsoonfollowed,aviationmedicinewasaddedin1953andoccupationalmedicinein1955.40(pp330-331)Whiletheciviliancommunitywrestledwiththeseeducationalissues,eventsweretranspiringintheAMEDDthatwouldculminateintheestablishmentofaformalArmyPreventiveMedicineResidencyProgram.DuringthetenureofSurgeonGeneralRaymondBliss,Armyhospitalsbeganofferingresidencytrainingprogramstocareerofficers.Healtheducationandpreventivemedicineprogramswereexpandedaswerelaboratories,andtheAMScontinuedtoproducepreventivemedicineofficers.52(pp118,120-21)ThewarinKoreaemphasizedagaintheneedforthesewell-trainedspecialists.LessonsincoldinjurypreventionfromWWIIhadtobere-learnedbycommanders,53atemperatestrainofPlasmodiumvivaxwhichlikedtohideintheliverformonthsputanewcomplicationinmalariachemoprophylaxisandtreatmentuntilprimaquinewasdevelopedandissuedin1951,54,55andonthepeninsulaUSforcesalsogottheirfirstintroductiontothehantavirus.56*References46(p48),47(pp11-12,16-17)

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14ArmyMedicalDepartmentJournalBytheearly1950s,theMilitaryPreventiveMedicineCourseofferedattherecentlyrenamedArmyMedicalDepartmentResearchandGraduateSchoolwas11monthslong.57Whileasteadysupplyofwelltrainedpreventivemedicineofficerswasneeded,recruitingintothisspecialtywasdifficult.Withthisinmind,SurgeonGeneralBlissproposedthattheschoolbegivenMastersofPublicHealth(MPH)andMastersofSciencedegreegrantingauthority,andhissuccessor,GeorgeArmstrong,tooktheactiontoCongress.Theseeffortsfailed,butthegauntletwastakenupbySurgeonGeneralSilasB.Haysin1956.57EarlyinhistenuretheProfessionalServiceSchoolwasrenamedtheWalterReedArmyInstituteofResearch(WRAIR)andtheAmericanBoardofPreventiveMedicinedeclaredtheMilitaryPreventiveMedicineCourseequivalenttoacivilianMPHprogram.TheboardalsoretroactivelyapprovedgrantingMPHdegreestotheWRAIRclassesof1954and1955.57However,attemptstosecurethesedegreesbyaffiliatingwitheitherJohnsHopkinsorGeorgeWashingtonUniversitywererejectedbythoseinstitutions.57Therefore,HayspresentedthedegreegrantingbilltoCongressonceagaininFebruary1957statingTheproposedlegislationwouldrecognizetheresponsibilityplacedonthisinstituteandwouldprovideitwiththestatuscommensuratewithitsactivities.HenotedtherecognitiongivenbytheAmericanBoardofPreventiveMedicineandthattherewasprecedentfortheproposedlegislation,inthattheNavyPostgraduateSchoolandtheAirForceInstituteofTechnologybothhaddegreegrantingauthority.57(p3)However,Dr.ArthurS.Adams,PresidentoftheAmericanCouncilonEducation,whospokeforleadersinhighereducation,testifiedthatitwasnotinthepublicinterestforanyfederalagencytobegivensuchauthority,and,thereby,essentiallydefeatedthebill.58SurgeonGeneralHaysabandonedhiseffortstoobtaindegreegrantingauthorityforWRAIRinSeptemberanddiscontinuedthe11-monthMilitaryPreventiveMedicineCourseafterthe1957-58session.Fromthatpointon,preventivemedicineresidentstooktheirMPHtrainingatcivilianinstitutionsandcompletedthelasttwoyearsofacademicandfieldtrainingrequirementsbyperformingthemconcurrentlyinaoneyearcourseatdesignatedArmymedicalfacilities.59,60(pp613-614)Beginningin1958,themilitarypreventivemedicineresidencyconsistedofathree-monthcourseinadvancedmilitarypreventivemedicineatWRAIRandoneyearatresidencyprogramsestablishedattheFortDixHealthCenterandFirstUSArmyPreventiveMedicineDivisioninNewJersey,underthedirectorshipofCOLGeorgeR.CarpenterandatthehospitalatFortOrdandthePresidioinCaliforniaunderCOLG.L.Orth.PlanswerealsodevelopedforanArmyOccupationalMedicineResidencyProgramattheArmyEnvironmentalHealthLaboratory,Edgewood,Maryland.60(p613),61OnJune1,1959LeonardD.HeatonbeganalonganddistinguishedcareerastheArmys31stSurgeonGeneral.Heatonhadahighregardforpreventivemedicine,andrecognizedthatitwasmorethanaspecialtywithinitself,butonethatpermeatedtherealmsofotherdisciplines,andassuchwasacruciallinkinmaintainingthestrengthoftheArmy.52(pp1,16)TheArmybegantogrowintheearly1960s.TheColdWarheatedupinBerlinin1961,leftthecitydividedandstimulatedabuildupofUSforcesinEurope.AyearlaterSovietmissilesinCubaputallservicesonhighalertandreinforcedtheneedforarapidlyresponsivemilitaryforce.Duringthistimealso,civicactionprogramsconductedbyArmySpecialForcesunitsinSoutheastAsiaandLatinAmericawereincreasing.62(ppiii,58,62),63Theseactivitieswerepreventivemedicineintensive,butattractingyoungofficersintothespecialtyremainedproblematic.ThroughintensifiedrecruitingtheSurgeonGeneralbegantofillthepreventivemedicineranks.WhiletheAMEDDdependedheavilyonshortcoursetrainedpreventivemedicineofficers,athirdresidencyprogramatFortBraggwasapprovedbytheAMAin1962,andafourthprogramatWRAIRtwoyearslater.62(p58),64TheinitiationoftheWRAIRprogramin1964coincidedtemporallywithPresidentJohnsonsannouncementoftheGulfofTonkinresolutionsandthemajorbuildupofforcesinVietnamthatbeganinearly1965.APreventiveMedicineDivision,OfficeoftheSurgeon,USArmy,RepublicofVietnamwasorganizedtoadvisethecommandontheincidence,prevalence,andepidemiologicalaspectsofdiseaseswhichwerelikelytoimpactcombatoperations.Indeed,inthisconflict,preventivemedicinewasinthevanofthedeployment.65(p108)In1973,MGSpurgeonNeelwroteOneofthemoststrikingachievementsofmilitarymedicineinVietnamwastherapidandeffective

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AprilJune200615establishmentofapreventivemedicineprogramthatbluntedtheimpactofdiseaseoncombatoperations.InWorldWarII,preventivemedicineprogramsintheFarEastdidnotbegintomakeinroadsupondiseaseincidenceuntil1945.InKoreathedelaywasless,butstillconsiderable.InVietnam,however,effectivediseasecontrolprogramswereintroducedin1965andmaintainedthroughoutthestressofthetroopbuildup.65(p32)Neelwastechnicallycorrect,buthispreventivemedicineeffortsinVietnamweremateriallyassistedbymedicaltechnologiesandlogisticalcapabilitiesthatwerenotavailableasAmericaenteredtheSecondWorldWarorKorea.Whathadnotchanged,however,anditisashamethatMGNeeldidnotpointitout,weretheessentialsofpostgraduatetraininginpreventivemedicineandpublichealthandtheabilityoftheWRAIRtoexpandtomeetmissiondemands.Althoughaccreditedresidencyprogramschangedtheformofthiseducation,thebasicshadbeentaughtandpracticedintheArmyforthreequartersofacenturyandthroughfivewars.SurgeonGeneralSternbergdidnotcallhisgraduatestudentsresidents,butinrealitythatisexactlywhattheywere.Withalittlebrushinguponcurrenttherapeuticpracticesandmodernfieldsanitationandhygienetechnologies,theArmyMedicalSchoolclassof1894wouldhavebeenjustascomfortableinthejunglesofVietnam,themountainsofAfghanistan,orthedesertsofIraqasthegraduatesoftoday.REFERENCES 1.BrintonJ.PersonalMemoirsofJohnH.Brinton,CivilWarSurgeon,1861-1865.NewYork:NealePub.Co;1914.Reprint.Carbondale,IL:SouthernIllinoisUniversityPress;1996.2.DuffyJ.HistoryofPublicHealthinNewYorkCity,1866-1966.NewYork:RussellSageFoundation;1974:92-102.3.SternbergM.GeorgeMillerSternberg.Chicago:AMA;1920.4.EggerthAH.TheHistoryoftheHoaglandLaboratory.NewYork:publisherundetermined;1960:45-48.5.GosselP.InstitutionalgrowthandthefateofbacteriologyatJohnsHopkins,18861923.PaperpresentedtotheJohnsHopkinsUniversityDepartmentofScience,Medicine,andTechnology;September28,2000;Baltimore,MD:79.6.AnnualReportoftheArmySurgeonGeneral,1894.Washington,DC:USWarDept;1894. TheWalterReedInstituteofResearch,circa1971

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16ArmyMedicalDepartmentJournal7.AnnualReportoftheArmySurgeonGeneral,1893.Washington,DC:USWarDept;1893:15.8.SternbergGM.ThefunctionoftheArmyMedicalSchool.AmMed.April1902;547-551:547-551.9.ReedW.ThegermicidalvalueofTrikresol.Proceedings,AssociationofMilitarySurgeonsoftheUnitedStates.St.Louis,MO:BuxtonandSkinnerStationeryCo,1894;199-208.10.SternbergGM,ReedW.Reportonimmunityagainstvaccinationconferreduponthemonkeybytheuseoftheserumofthevaccinatedcalfandmonkey.TransAssoAmPhys.1895;10:57-69.11.ReedW,CarrollJ.Bacillusicteroidesandbacilluscholeraesuisapreliminarynote.MedNewsApril29,1899;74:513-514.12.ReedW,CarrollJ,AgramonteA,LazearJ.Theetiologyofyellowfever:apreliminarynote.PhilMedJ.October27,1900;6:790-796.13.ReedW,VaughnVC,ShakespeareEO.OriginandSpreadofTyphoidFeverinU.S.MilitaryCampsDuringtheSpanishWarof1898[abstract].Washington,DC:USWarDept;1900.14.AnnualReportoftheArmySurgeonGeneral,1899,Washington,DC:USWarDept;1899:19.15.AnnualReportoftheArmySurgeonGeneral,1902.Washington,DC:USWarDept;1902:14-15.16.AnnualReportoftheArmySurgeonGeneral,1900.Washington,DC:USWarDept;1900.17.AnnualReportoftheArmySurgeonGeneral,1904.Washington,DC:USWarDept;1904.18.AnnualReportoftheArmySurgeonGeneral,1907.Washington,DC:USWarDept;1907.19.AnnualReportoftheArmySurgeonGeneral,1905.Washington,DC:USWarDept;1905:134.20.GillettM.TheArmyMedicalDepartment,1865-1917.Washington,DC:USDeptoftheArmy,CenterforMilitaryHistory;1995.21.AnnualReportoftheArmySurgeonGeneral,1909.Washington,DC:USWarDept;1909.22.AnnualReportoftheArmySurgeonGeneral,1910.Washington,DC:USWarDept;1910.23.AnnualReportoftheArmySurgeonGeneral,1908.Washington,DC:USWarDept;1908:105.24.VedderE.Beri-Beri.NewYork:WillliamWood&Co;1913.25.AnnualReportoftheArmySurgeonGeneral,1914.Washington,DC:USWarDept;1914.26.MunsonE.MilitaryHygiene.NewYork:WilliamWood&Co.;1901:171.27.AnnualReportoftheArmySurgeonGeneral,1915.Washington,DC:USWarDept;1915.28.AnnualReportoftheArmySurgeonGeneral,1916.Washington,DC:USWarDept;1916.29.AnnualReportoftheArmySurgeonGeneral,1917.Washington,DC:USWarDept;1917:298-301.30.AnnualReportoftheArmySurgeonGeneral,1918.Washington,DC:USWarDept;1918:438-443:68-70.31.ChamberlainWL,WeedFW.Sanitation.Washington,DC:USWarDept;1926.TheMedicalDepartmentintheWorldWar;vol6.32.HumeEE.VictoriesofArmyMedicine.Philadelphia,PA:JBLippincottCo.;1943.33.CircularofInformation,GeorgetownUniversitySchoolofMedicine,1903-04.WashingtonDC:GeorgetownUniversityArchives:19.34.SternbergGM.Preventivemedicine.PopularScienceMonthly.February1903;62:348-358.35.RecordoftheBoardofTrustees,ColumbianUniversity,June18,1902-May26,1910.Washington,DC:GelmanLibraryArchives,GeorgeWashingtonUniversity:169-171,174,242,419.36.OpeningSessionMonday.WashingtonEveningStar.January10,1903.37.FeeE,AchesonRM,eds.AHistoryofEducationinPublicHealth.NewYork:OxfordUniversityPress;1991.38.DuffyJ.TheSanitarians,AHistoryofPublicHealth,Urbana,IL:UniversityofChicagoPress;1992.39.RosenG.AHistoryofPublicHealth.NewYork:MDPublications;1958:253.40.StevensR.AmericanMedicineandPublicInterest,2nded.LosAngeles,CA:UniversityofCaliforniaPress;1998.41.AnnualReportoftheArmySurgeonGeneral,1924.Washington,DC:USWarDept;1924.42.AnnualReportoftheArmySurgeonGeneral,1923.Washington,DC:USWarDept;1923:257.43.AnnualReportoftheArmySurgeonGeneral,1929.Washington,DC:USWarDept;1929:310.44.HistoryoftheArmyMedicalDepartmentResearchandGraduateSchool[unpublished].Washington,DC:ArchivesoftheWalterReedArmyInstituteofResearch:21.45.Bayne-JonesS.TheEvolutionofPreventiveMedicineintheUnitedStatesArmy,1607-1939.Washington,DC:USDeptoftheArmy;1968.

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AprilJune200617 46.CoatesJB.CommunicableDiseases:Malaria.Washington,DC:USDeptoftheArmy;1963.PreventiveMedicineinWorldWarII;vol6.47.AndersonRS.SpecialFields.Washington,DC:USDeptoftheArmy;1969.PreventiveMedicineinWorldWarII;vol9.48.HumeJC.Developmentofresidencytraininginpreventivemedicine.JAMA.1966;198;No.3:270-274.49.LudmererKM.TimetoHeal.NewYork:OxfordUniversityPress;1999:181-192.50.WhayneTF.Preventivemedicineinmedicalschools.ArchEnvHealth.1961;3:308-314.51.Approvedinternshipsandresidencies.JAMA.September29,1951;147:442.52.EngelmanRC,ed.ADecadeofProgress:TheUnitedStatesArmyMedicalDepartment,1959-1969.Washington,DC:USDeptoftheArmy;1971.53.WhayneTF,DeBakeyME.ColdInjury,GroundType;MedicalDepartmentoftheUnitedStatesArmyinWorldWarII.Washington,DC:USDeptoftheArmy;1958:ix.54.MarshallIH.MalariainKorea.RecentAdvancesinMedicineandSurgery.Vol2.Washington,DC:ArmyMedicalServiceGraduateSchool,WalterReedArmyMedicalCenter;1954.55.DilorenzoA,MarxRL,AlvingAS.Koreanvivaxmalaria.AmJTropMed&Hyg.1953;2:984-984.56.MayerCF.EpidemichemorrhagicfeveroftheFarEast,orendemicnephroso-nephritis.MilitSurg.April1952:276-284.57.DegreeGrantingActivitiesforWRAIR.RG112,E421Box59,NationalArchivesandRecordsAdministration.58.MeetingMinutes,5Mar1957.DegreeGrantingActivitiesforWRAIR.RG112,E421,Box52,NationalArchivesandRecordsAdministration.59.AnnualHistory,PreventiveMedicineDivision,1957,39-40.AnnualReportsofDivisionsofSGO,1947-1974.RG112,E1018,Box10,NationalArchivesandRecordsAdministration.60.ApprovedResidenciesandFellowships,JAMA.1958;168:613.61.AnnualReportoftheArmySurgeonGeneral,1958.Washington,DC:USDeptoftheArmy;1958:38.62.AnnualReportoftheArmySurgeonGeneral,1962.Washington,DC:USDeptoftheArmy;1962.63.AnnualReportoftheArmySurgeonGeneral,1963.Washington,DC:USDeptoftheArmy;1963:28.64.AnnualReportoftheArmySurgeonGeneral,1966.Washington,DC:USDeptoftheArmy;1966:115.65.NeelS.MedicalSupportoftheU.S.ArmyinVietnam,1965-1970.Washington,DC:USDeptoftheArmy;1973.AUTHOR COLCraigistheAMEDDConsultantinMedicalCorpsHistory.HeisaprofessorattheUniformedServicesUniversityoftheHealthSciencesinBethesda,MarylandwhereheistheCourseSupervisorfortheMS-IcourseinMilitaryMedicine.COLCraigisamemberoftheEditorialReviewBoardoftheAMEDDJournal.COLADAMSJOINSTHEAMEDDJOURNALEDITORIALREVIEWBOARDTheAMEDDJournalwelcomesCOLGeorgeL.Adams,MS,USAasamemberoftheEditorialReviewBoard.COLAdamsistheSeniorAssistanttotheChief,MedicalServiceCorps,AMEDDCenter&School,FortSamHouston,Texas.COLAdamsjoinstheboardreplacingCOLGeorgeJ.Dydek,MS,USA.COLDydekhasbeenamemberoftheBoardsinceJanuary,2000.WethankCOLDydekforhisdedicationtothehighstandardsandprofessionalqualityofthispublication,andhisyearsofserviceandsupporttoourmission.TheEditors

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18ArmyMedicalDepartmentJournalOverthepast25years,EnvironmentalScienceOfficers(AreaofConcentration[AOC]72D)andEnvironmentalEngineers(AOC72E)haveplayedanincreasinglyvitalroleinwhathasbecomeknownasforcehealthprotection.TheArmyhashistoricallyrecognizedtheimportanceofenvironmentalandoccupationalhealthservicesasthepreeminenttoolstoconservethefightingstrengthofSoldiers(andcivilians),whetherthesepersonnelaredeployedoperationallyorworkingandtrainingonmyriadinstallationsaroundtheworld.ThishasremainedtrueevenastheArmyhaschangedtoadaptfromtherequirementsoftheColdWartomeetthechallengesoftheGlobalWaronTerrorism.However,itismyobservationthattherolesandmissionsof72Dand72Eofficershavenotonlyevolved,buthavealsogrownsoclosetooneanotherthattheyarevirtuallyindistinguishable.EnvironmentalScienceOfficers(ESOs)andEnvironmentalEngineersarebothconcernedwiththatportionofthepublichealthspectrumknownasenvironmentalhealth.Broadlydefined,environmentalhealthandprotectionreferstoprotectionagainstenvironmentalfactorswhichmayadverselyimpacthumanhealthortheecologicalbalancesessentialtolong-termhumanandenvironmentalquality,whetherinthenaturalorman-madeenvironment.1Althoughcomplementarytoeachother,72Dand72Eofficersdifferintheiracademicbackgroundsandprimaryfocus.Environmentalengineerspossessundergraduatedegreesincivil,mechanical,orenvironmentalengineering,andaretraditionallyconcernedwiththeconstruction,maintenance,anddevelopmentofwaterandwastewatersystems,airpollutioncontrolmeasures,andsolidwastemanagementsystems,allofwhichplayimportantrolesinthemaintenanceofpublichealth.Ontheotherhand,ESOshavetraditionallyearnedundergraduatedegreesinthebiologicalorphysicalsciencesandareconcernedwiththeimplementationandexecutionofprogramsfordrinkingwaterqualitysurveillance;appliedfoodservicesanitation,housingsanitation,pestcontrol,diseasesurveillance,andgeneralenvironmentalquality.BothESOsandenvironmentalengineerscanfindthemselvesengagedinprovidingindustrialhygienesupporttoinstallationoccupationalhealthprograms,aswellasmonitoringforthepresenceandextentoftoxicindustrialmaterials/compoundsinthesurroundingair,soil,andwater.WhilethecontributionsofthesespecialtiestotheArmyandtheArmyMedicalDepartment(AMEDD)haveneverbeenmoreimportant,itisinterestingtonotethattherelativeproportionofengineersandESOswithintheMedicalServiceCorpshaschangeddramaticallyalongwiththeArmysexpectationofwhattheseofficersmustdeliverinthewayofsupporttodeployedforces.ORIGINOFSANITARY/ENVIRONMENTALENGINEERSANDENVIRONMENTALSCIENCEOFFICERSEnvironmentalengineers(untilrecentlyknownassanitaryengineers)haveservedintheArmysincetheFirstWorldWar.InJune1917,thenSurgeonGeneralWilliamGorgascreatedtheUSArmySanitaryCorpswhichenrollednewlycommissionedofficerswithspecialskillsinsanitation,sanitaryengineering,inbacteriology,orothersciencesrelatedtosanitationandpreventivemedicine,orwhopossessotherknowledgeofspecialadvantagetotheMedicalDepartment."2ThefirstofficerappointedinthenewSanitaryCorpswasanengineerbythenameofWilliamWrightsonwhohadservedwithGorgasinPanamaduringtheconstructionofthePanamaCanal.ByNovember1918,sanitaryengineersnumbered213andcomprised7.5%ofentireSanitaryCorps.Sanitary/EnvironmentalengineershavebeenwiththeAMEDDeversincethattime,providingsanitary/publichealthsupportandindustrialhygieneservicesaroundtheworldandineverymajorconflictandcontingencythroughoutthe20thcentury.In1961therewere99SanitaryTheEvolvingRoleofEnvironmentalScienceOfficersandEnvironmentalEngineersintheMedicalServiceCorpsCOLJohnJ.Ciesla,MS,USA

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AprilJune200619Engineersonactiveduty,anumberthatremainedfairlysteadyforthenext20years(94wereservingwiththeMedicalServiceCorpsin1982).3(apndxK,L)EnvironmentalScienceOfficersareamorerecentdevelopment.InNovember1968,thefirst7sanitarians(latercalledenvironmentalscienceofficers)deployedtoVietnam.PraisedbyboththeUSArmyVietnam(USARV)SurgeonandUSARVSanitaryEngineer,theseofficerswerejudgedmoreeffectiveatthedivisionlevelforday-to-daypreventivemedicineactivitiesthantheMedicalCorpspreventivemedicineofficerstheyreplaced.4,5By1972thenumberofESOsservingintheMedicalServiceCorpshadrisento90;andby1982thisnumberhadrisenfurtherstillto143.By1994theaggregatenumberofESOsandSanitaryEngineerstotaled240,althoughESOsoutnumberedengineersbyabout2to1.3(apndxM)In2006,thereare197ESOsand54Environmental/SanitaryEngineersonactivedutyintheMedicalServiceCorps.6CHANGINGROLESANDMISSIONSPriorto1985,thetendencywastoassignenvironmentalengineerstoscientific/technicalorganizationswithintheAMEDD,suchastheUSArmyEnvironmentalHygieneAgencyorthe10thMedicalLaboratory.TheseengineersalsoprovidedsupportasstaffofficersattheDepartmentoftheArmylevelorOfficeofTheSurgeonGeneral,aswellasatmajorsubordinatecommandssuchasHSC(HealthServicesCommand,theprecursortotheMedicalCommand).TheyalsoservedasinstructorsandcombatdeveloperswiththeAMEDDCenter&School.Althoughenvironmentalengineerswererarelydirectlyinvolvedintheconstructionofwaterandwastewaterplantsorsanitarylandfills(becausetheArmyincreasinglyprivatizedtheseactivities),theynonethelesscontinuedtoadviseonorperformprofessionalandscientificworkutilizingengineeringpracticestoprotectSoldiershealth,andsupportArmyenvironmentalprotectionandpreservationefforts.Dutiescouldalsoincludetheassessmentofexistingandproposedweaponssystems,equipment,clothing,trainingdevices,andmaterielsystems.EngineerswithtrainingandexperienceinindustrialhygieneprovidedinvaluableassessmentsofworkplacehealthandsafetyinsupportoftheArmyOccupationalHealthProgram.Atthissametime,ESOswereprimarilyassignedatinstallationleveltotheMEDDAC(MedicalDepartmentactivity)PreventiveMedicineServicestoserveastheChiefofEnvironmentalHealth.Justastheyhaddonein1968inVietnam,ESOsconsistentlydemonstratedtheirflexibilityandadaptabilityindirectingenvironmentalhealthprogramsthatincludeddrinkingwatersurveillance,foodservicefacilityinspections,supportforchildcarecenterandhousingsanitation,pestcontrol,andindustrialhygienesurveys.Intheabsenceofapreventivemedicinephysician,these72DofficerscouldalsofindthemselvespressedintoserviceastheChiefofPreventiveMedicine.Alternatively,ESOscouldalsofindthemselvesassignedtoTableofOrganization&Equipment(TO&E)preventivemedicinepositionsasthedivisionESO,commanderofapreventivemedicinedetachment,specialforcesgroupESO,orstaffESOataMedicalGrouporBrigade.Liketheir72Ecounterparts,ESOsalsowereassignedtotheAMEDDCenter&Schoolasbothinstructorsandcombatdevelopers.Around1985,anincreasingnumberofenvironmentalengineersexpressedadesiretoserveinfield(TO&E)units.Consequently,engineerswereassignedto72DpositionsatArmydivisions,specialforcesgroups,andpreventivemedicinedetachments.Atthissametime,ESOswereincreasinglyassignedtothosepositionsthat,althoughpreviouslyreservedfor72Eofficers,werenolongerdeterminedtostrictlyrequireanengineerorengineeringexpertise.Consequently,72Dand72EofficersbecameincreasinglyinterchangeableforallbutarelativehandfulofTO&EorTableofDistributionandAllowances(TDA)assignments.Thissituationremainsunchangedtoday.Whileexpectationsonwhatconstitutesinstallationenvironmentalhealthandenvironmentalqualitysupporthasnotchangedoverthepast25years(andisstillspelledoutinArmyRegulation40-5anditssupportingdocuments7),itisnoteworthythattheunderstandingofwhatconstitutesthemissionforTO&Epreventivemedicineorganizationsprovidingoperationalsupporttodeployedforceshasbeenrevolutionized.PriortothefirstGulfWarin1991,fieldpreventivemedicinesupportwasconsideredimportantbutnotparticularlychallengingfromatechnicalstandpoint.Forexample,fieldwatersurveillancewaslargelylimitedtocoliformbacteriadeterminations,testingchlorineresiduals,andperformingarelativelylimitedsuiteofinorganicchemicaltests.Environmentalsurveillancewasusuallylimitedtowhatwasdirectlyobservedduringsanitary

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20ArmyMedicalDepartmentJournalsurveys,andwiththeintroductionofhermetically-sealedfieldrationssuchasMREs(Meal,Ready-to-Eat)andT-Rations,therewaslesstobeconcernedaboutfromanappliedfoodservicesanitationstandpoint.Industrialhygienesurveyswereordinarilylimitedtomeasurementsofcarbonmonoxide.Evenentomologicalsurveillancetechniqueswererudimentary.However,the1991GulfWarandresultingoilwellfiresproducedadramaticincreaseinconcernaboutSoldierexposuretoindustrialchemicalsandtoxicmaterialsduringdeployments.Asaresult,ESOsandenvironmentalengineersassignedtoTO&Epreventivemedicineunitsarenowexpectedtoperformenvironmentalcontaminantriskassessmentswhicharethenincorporatedintocommandersriskmanagementactivities.BeginningwiththedeploymentofUSarmedforcestoBosniain1996,newprotocolsforwhatwouldbecomeknownasDeploymentOccupationalandEnvironmentalHealthSurveillance(OEHS)wouldrequire72Dand72Eofficerstoperformanalysisoftheair,soil,andwatersuppliesateverymajorbasecamporforwardoperatingbase.TheseanalyseswouldexceedinscopeandcomplexitywhatisroutinelyaccomplishedatArmypostsaroundtheworldandinmostUSmunicipalities.ThistrendhascontinuedbecauseUStroopsincreasinglymakeuseofformerSovietbasesandinfrastructureorencounterthird-worldenvironmentalconditionsthatincreasethepotentialforexposuretotoxicindustrialcompoundsandchemicals.From1996tothepresent,whereverUSgroundforceswereemployed,ESOsandenvironmentalengineersassignedtoTO&EunitscollaboratedwiththeircolleaguesfromtheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)toproducedetailedOEHSassessmentsofmajorbasecampsandforwardoperatingsitesinMacedonia,Kosovo,Uzbekistan,Afghanistan,Kuwait,andIraq,aswellasotherlocationsofoperationalinterestaroundtheworld.Althoughclassicfieldsanitationandhygienemissionsremainimportant(asunderscoredduringtheearlyphasesofOperationsEnduringFreedomandIraqiFreedom),thisnewdemandforOEHSsupportrequiresequipment,tacticsandtechniquesthatarejustastechnicallychallengingasthatrequiredtoprovideindustrialhygieneandenvironmentalhealthsupportatanypermanentinstallation.IthasproducednewchallengesfortheAMEDDinhowittrainsandemploysESOsandenvironmentalengineers.OEHSandforcehealthprotectionrequirementshavealsomadethepresenceofa72D/Eofficeronthestaffofmostcombatantcommands(CentralCommand,SouthernCommand,etc.)moreimportantthanever.ARMYTRANSFORMATIONThevalueplacedonthesupportprovidedby72D/EofficershasbeenunambiguouslyreinforcedbythenewmodularorganizationsdevelopedtosupportArmyTransformation.Beginningin2004,eachnewbrigadecombatteamhasa72Dassigned,asdoeseachdivisionheadquarters.ThisbringsthetotalnumberofESOswithinadivisiontofour,adramaticincreasefromthesingleofficerassignedinthepast.Additionally,everyarmyandcorpsheadquartersmayhaveuptothree72Dofficersassignedtoitsmainandoperationalcommandposts.Addtothesepositionsnewauthorizationsforbothcompany-gradeandfield-grade72D/Eofficersateveryproposedmedicaldeploymentsupportcommand,medicalsupportcommand(MSC),multifunctionalmedicalbattalion,sustainmentcommand,militarypolicebattalion,andcivilaffairs

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AprilJune200621brigade,andtheresultisa4-foldincreaseinthenumberof72DTO&EauthorizationswithintheActiveComponent.In2007,the197activeESOauthorizationsarealmostevenlydividedbetweenTDAandTO&Epositionsateverygradelevel,somethingwhichwillfacilitatethecareerdevelopmentofESOsandenvironmentalengineersbypermittingofficerstorotatebackandforthbetweenoperationalandinstitutionalassignmentsthroughouttheircareers.THEFUTUREOFESOSANDENVIRONMENTALENGINEERSESOsandenvironmentalengineerswillcontinuetoserveasvaluablemembersoftheAMEDDteamandmakeadirectcontributiontoforcehealthprotection.Thefutureisundeniablybright.Butevenwithagrowingdemandfor72D/Eofficers,severalissuesremaintobeaddressedinthenextfewyears:TheMedicalServiceCorpswillneedtodeterminehowmany72Dand72Eofficersitneedsasacomponentofitstotalbudgetedendstrength.In1980,therewereapproximately245ESOsandenvironmentalengineersonactivedutyprovidingsupporttoa780,000SoldierArmy.In2006,morethan27572D/EofficersserveinanArmyalmostone-thirdsmaller,andbaseduponprojections,thenumberofauthorizationsfor72DofficersintheTO&EforcewillcontinuetogrowtosupportArmyTransformation.AtwhatpointwilltheMSCdecidethatithasalltheESOsthatitcanaffordinlieuofotheroperationalrequirements?SinceESOsexceedthenumberofenvironmentalengineersbyalmost3to1,andthe2AOCsareinterchangeableinmostassignments,ismaintaining2separateAOCsforESOsandengineersstillviable?WouldanadditionalskillidentifierforengineersbeabettermeanstoidentifythisvaluableskillsetfortheMSC?WhichpositionswithintheAMEDDabsolutelyrequiretheskillsofanengineerandshouldbedesignatedassuch?Are72EengineersatriskofbecomingcivilianizedbecauseoftheircurrentlylowrepresentationintheTO&Eforce?Approximately10%of72EpositionsareTO&Eversusapproximately50%ofESOpositions.WhichTDApositionswithinMEDCOMwillprovidethebesttechnicalandprofessionalopportunitiesfor72D/Eofficers?IsanassignmenttoUSACHPPMbetterthananassignmenttoaMEDDAC?ShouldsomeMEDDACESOpositionsbeconvertedundercurrentmilitary-to-civilianinitiativesinordertoprovidebetterdevelopmentalopportunitiesforjuniorofficerselsewhere?TheseandotherquestionswillbediscussedinthenextfewyearsbytheseniorleadershipoftheMedicalServiceCorpsincollaborationwiththecompany-andfield-gradeESOsandenvironmentalengineerscurrentlyservingaroundtheworld.Regardlessoftheoutcomeofthesedeliberations,thefutureforMSCenvironmentalscienceofficersandenvironmentalengineerswillcontinuetobeexcitingandfullofenormouspotentialforpersonalandprofessionaldevelopment.WiththeincreasedemphasisbytheArmyonforcehealthprotectioninaglobalenvironment,theseofficerswillcontinuetoplayanindispensableroleintheAMEDDsmissiontoprotectthefightingstrength.REFERENCES 1.DefinitionofEnvironmentalHealthadoptedbytheNationalAssociationofEnvironmentalHealth(NEHA),April1996.Availableat:http://www.neha.org/position_papers/def_env_health.html.2.WarDepartmentGeneralOrderNo.80.Washington,DC:USWarDept;30June1917.3.GinnRVN.TheHistoryoftheU.S.ArmyMedicalServiceCorps.Washington,DC:USArmyCenterofMilitaryHistory;1997.4.JenningsHB.Sanitarians.PresentedatSeniorOfficerDebrief,USArmyVietnam:25June1969.5.SmithJJ.OfficeofTheArmySurgeonGeneralLessonsLearned:23October1968.6.AOC72D/EInventoryData.Washington,DC:USArmyHumanResourcesCommand;April2006.7.ArmyRegulation40-5:PreventiveMedicine.Washington,DC:USDeptoftheArmy;July22,2005.AUTHOR COLCieslaistheEnvironmentalScienceandEngineeringConsultanttoTheArmySurgeonGeneral

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22ArmyMedicalDepartmentJournalINTRODUCTIONEpidemiologyisthestudyofpatternsandriskfactorsfordiseaseandinjuryoccurrenceinpopulationswiththeintenttodetermineapproachestomitigateadversehealthoutcomesandpreventfuturemorbidityandmortality.Healthsurveillanceistheroutineandsystematiccollection,analysis,interpretation,andreportingofpopulation-baseddataforthepurposesofdetecting,characterizing,andcounteringthreatstothehealth,fitness,andwellbeingofpopulations.Inmilitarysettings,epidemiologyandsurveillancearerequiredtomaintainhealthy,fit,andoperationallyeffectiveforcesandtoensuretheirhealthandsafetyduringbothtrainingandreal-worldmissions.Publichealthpractitionersuseepidemiologyandsurveillancetoservepopulationsinthesamewaythatmedicalcareprovidersuseclinicaldiagnosisandscreeningtoserveindividualpatients.Figure1comparesindividualcareandpopulationmedicinewithregardtothescientificproblem-solvingprocess.Figure2showshowepidemiologyandsurveillancefunctioninthebroaderschemeofcontinuouspublichealthassessmentandintervention.HISTORICALPERSPECTIVEJustascombatcasualtycareandthetreatmentofacutediseasesforwhichdeployedtroopsareathighriskhaveevolvedwitheachmajorUSmilitaryengagementthroughhistory,sotoohaveepidemiologicaltoolsandprocedures.TheearliestMedicalDepartmentregulationthatattemptedtotiethemonitoringofscientificdatatopredictingdiseaseoccurrenceinpopulationswaspublishedin1826.Itrequiredphysicianstomaintainmeteorologicalrecords.TheArmySurgeonGeneralatthattimewasJosephLovell,whoalsoinitiatedtheuseofphysicalstandardsforsoldierrecruitmentandmassvaccination(againstsmallpox)ofnewrecruitsbasedontheirhistoryofpriorvaccinationordisease.In1874,WarDepartmentGeneralOrdersNo.125substantiallystrengthenedhygienerequirementsatmilitaryposts,stations,andcamps.Inparticular,theMonthlySanitaryReportwasArmyEpidemiologyandHealthSurveillanceCOLBrunoPetruccelli,MC,USAJosephKnapik,ScDFigure1.Comparisonofindividualcare(clinician)andpopulationmedicine(epidemiologist)practitionerfunctionswithregardtostepsinthescientificproblem-solvingprocess.ScientificProblemSolvingProcessPractitionerDatabaseAssessmentHypothesisTestingAction ClinicianHistoryPhysicalExamDifferentialDiagnosisDiagnosticStudiesTreatment EpidemiologistSurveillanceDescriptiveEpidemiologyInferenceAnalyticalEpidemiologyCommunityIntervention

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AprilJune200623establishedaprecursoroflocalcommandhealthreportsand,centrally,todaysMedicalSurveillanceMonthlyReport.*Twentyyearslater,SurgeonGeneralGeorgeSternbergestablishedagraduateinstitutionpreparingphysicianstobecomeArmymedicalofficers:TheArmyMedicalSchool,precursoroftheWalterReedArmyInstituteofResearch.Itwasherethattheearliestepidemiologicalfieldinvestigationsofmilitaryimportancewerelaunched,includingthosedirectedbythefamousTyphoidandYellowFeverBoardsinwhichWalterReedplayedacentralrole.2Later,WorldWarIIraisedtheneedfor2relativelysmallbutimportantUSmilitarypublichealthentities:theBoardfortheInvestigationandControlofInfluenzaandOtherEpidemicDiseasesintheArmy(whichtodayisnamedtheArmedForcesEpidemiologyBoard),andtheArmyIndustrialHygieneLaboratory(whichtodayisthemuchlargerUSArmyCenterforHealthPromotionandPreventiveMedicine).SURVEILLANCEANDANALYSISThereare2broadsurveillanceprocedurecategories,activeandpassive.Insimpleterms,activesurveillancerequireseitherthedatacollectororthereportertobeonthelookoutforeventsofpublichealthinterestandtorecordortransmittherelevantdataaspartofan*Availableat:http://www.amsa.army.mil HazardsExposuresRiskFactorsOutcomesCountermeasuresHazardsExposuresRiskFactorsOutcomesCountermeasures EpidemiologyandBasicInvestigation/Research InterventionResearch Step1EnvironmentHost ActionandPrevention MedicalSurveillancePrimaryDatabasesDeathHospitalizationDisabilityOutpatientPerformance ReporttoDecisionMakers,PolicyMakers,ActionAgenciesOCCURRENCEDETECTIONRESPONSE Step2 Step3 Step4 Step5 AgentINJURYorDISEASE EpidemiologyandBasicInvestigation/Research InterventionResearch Step1EnvironmentHost ActionandPrevention MedicalSurveillancePrimaryDatabasesDeathHospitalizationDisabilityOutpatientPerformance ReporttoDecisionMakers,PolicyMakers,ActionAgenciesOCCURRENCEDETECTIONRESPONSE Step2 Step3 Step4 Step5 AgentINJURYorDISEASESteps1-5=StepsofthePublicHealthStep1.IdentificationofproblemsStep2.DeterminationofcausesStep3.DeterminationofwhatworkstopreventtheproblemStep4.ImplementationofprogramsStep5.Monitoring/surveillanceandevaluationofprogram/strategyeffectiveness TheRiskManagementStep1.IdentifyhazardsStep2.AssesshazardsStep3.DevelopcontrolsandmakedecisionsStep4.ImplementcontrolsStep5.Superviseandevaluate Figure2.Therelationshipofepidemiologyandsurveillanceinthebroaderschemeofcontinuouspublichealthassessmentandintervention.1

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24ArmyMedicalDepartmentJournalexertedeffort.Examplesincludelocalpreventivemedicinepersonnelregularlysearchingrecordsorqueryingdatabasestofindclinicaloutcomesofinterest,orclinicalpersonnelatsentinelsitessendingreportsbecausetheyareparticipatinginanorganizedsurveillanceprogram.Passivesurveillanceoccursinthebackground,inthateitherthereporterismakingnospecialefforttotransmitdataforpublichealthpurposes(eg,thedataarebeingcollectedforbillingorotherpurposesanyway)ortheagencycollecting,archiving,andanalyzingdataofinterestreliesontheindependentknowledgeandeffortofreporterstofeedsuchdata,simplybecauseitistheappropriatethingforsuchreporterstodo(eg,clinicianormicrobiologistoriginatedreportablediseasecommunication).Factorsthatdictatewhetherornotaparticularconditionshouldbereportableincludepreventability(eg,interruptibletransmission,availablevaccine,andprovensafetyproceduresthatmayrequirerenewedcommandemphasis),outbreakpotential,possibleoffensiveuseofthecausativeagent,andthedegreetowhichtheconditionisknowntobeveryrareoreliminatedeithergloballyorinaparticulargeographicarea.Thebaseofreportingvariesbothbylocationwithinthehealthcaresystem(clinicversuslaboratory)andbymilitarysetting(deploymentversusgarrison).Theunderlyingeventsorconditionsofinterestareeitherexposure-oroutcome-based.Exposure-basedeventsorconditionsarefromthegeneralorimmediate(eg,occupational)environment,ortheyareimposeddirectlyonindividuals(eg,vaccinations).Outcome-basedeventsareeitherdiseasesorinjuries,thoughatthetissueleveltheseareusuallyoneandthesame,hencethegenericmeaningofdiseasesurveillance.Thedatathemselvesrepresentepisodiceventsofinterest(eg,reportableconditions)orcompletecaptureofallhealthcareencounters.Groupingorcategorizationofdatacanoccurateitherthesitewherereportsaregenerated(eg,diseaseandnonbattleinjuryreports)orthearchivingcenter(eg,foranalysisor[automatically]usingmodernsyndromicsurveillance*programs).TheArmyistheexecutiveagentforhealthsurveillance.TheUSArmyCenterforHealthPromotionandPreventiveMedicine(CHPPM)overseesthecollection,archiving,andanalysisofhealthsurveillancedatatoexecutethismission.CHPPMsArmyMedicalSurveillanceActivitymanagestheDefenseMedicalSurveillanceSystem(Figure3)whicharchiveshealth-relevantdatathatarelinkeddirectlytomilitarypersonnelandwhich,inturn,isalsolinkabletotheDepartmentofDefenseSerumRepository(DoDSR).CHPPMsDeploymentEnvironmentalSurveillanceProgramperformsfunctionslinkeddirectlytospecificgeographicandworkplaceenvironmentssuchasfieldtesting,datamonitoring,andcreatingandmaintainingarchivesoftheresultsoflaboratoryanalysisofenvironmentalsamples(eg,air,soil,water).Knowledgeofthehealthrisksfromoccupationalandenvironmentalexposurescanbenefitfieldcommandersandunitsurgeonstoassessthemedicalthreatanddetermineappropriatecountermeasures.CHPPMhasalsomanagedthedesign,development,implementation,integration,andsupportactivitiesfortheDefenseOccupational&EnvironmentalHealthReadinessSystem(DOEHRS),whichiscurrentlybeingfielded.TheDOEHRSwillhelpintegrateforcehealthprotectioninformationbyprovidingautomatedsupportforthemilitaryhealthsystemindustrialhygienists,environmentalhealthspecialists,audiologistsresponsibleforhearingconservation,andotherpreventiveandoccupationalmedicinepersonnel.Thegoalistohavearepositoryofretrievableandanalyzablerecordscontainingahistoryofindividualworker(especiallytroop)exposuresinbothgarrisonanddeployedsettings.TheGlobalEmergingInfectionsSurveillanceandResponseSystem(DoD-GEIS),forwhichtheArmyisalsoexecutiveagent,overseestheconductoffocused,microbiologicalsurveillanceactivitiesatvariousDoDlaboratoriesworldwide,andatthepublichealthcentersoftheAirForce,Army,andNavy.Whileitscentralorganizationisstillrelativelysmall,theDoD-GEIStapsabroadnetworkofcollaboratingexpertsandlaboratoriestoprovideemerginginfectiousdiseaseconsultation;identifyvulnerabilitiesinsurveillance,response,andinfrastructure;andassistDoDpartnerstodevelopprojectsandimplementprogramsthatmitigateemerginginfectionthreats.AnotherArmyexecutiveagencywithsurveillance-relatedactivitiesistheArmedForcesInstituteofPathology,withinwhichtheOfficeoftheArmedForcesMedicalExaminermaintainsadatabasedocumentingoccurrencesandcausesofdeathsofUSmilitarypersonnelworldwide.*SyndromicsurveillanceThetrackingofcategoriesof outpatientclinicalpresentationsfrommultiplegeographicsitestorevealtrendsrequiringfurtherinvestigationofpossibleepidemicsorattackswithweaponsofmassdestruction,ortocharacterizesuchtrendsovertime.Seerelatedarticleonpage46.

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AprilJune200625

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26ArmyMedicalDepartmentJournalTheOfficeoftheAssistantSecretaryofDefenseforHealthAffairs(ASD-HA),throughtheDeputyASDforForceHealthProtection,isoverseeingaprocessofimprovednetworkingamongthesevariousentities,aswellasanactualintegrationofcentralizedarchiving,analysis,andreportingfunctionstoestablishwhatmaybecomeanArmedForcesHealthSurveillanceCenter.TheArmyMedicalDepartment(AMEDD)wouldthenmanageatrulymulti-Serviceorganizationwithenhancedcapability.Inthemeantime,someofthestaffoftheASD-HAarethemselvesdirectlymanagingcontractstomaintainspecificsurveillancefunctionsthatevolvedveryquicklysincetheattacksofSeptember11,2001,andtheassociatedrecognitionoftheincreasedthreatofweaponsofmassdestruction,particularlybiologicalagents.Inparticular,asecureenvironmentwithrobustwebbasedaccesswasrequiredtoreceivediseaseandnonbattleinjury(DNBI)datainnearrealtimefromtherathercomplexCentralCommandareasofoperation;andadedicatedserverwasrequiredforoperationofdaily,worldwidesyndromicsurveillance.Tomeettheserequirements,respectively,theJointMedicalWorkStationandtheElectronicSurveillanceSystemforEarlyNotificationofCommunity-basedEventsweredevelopedandarecurrentlyoperatedatHealthAffairscollocatedoffices.Diseaseandnonbattleinjurysurveillancehasevolvedsubstantiallyovertheyears.Formostofthe20thcentury,diseasesandinjuriestreatedatcorpsortheaterlevelhospitalsallowedcommandsurgeonstomonitortrendsthatmightrequirespecialintervention.Overthelast25yearsthepracticeofincludingnonhospitalencountersinDNBIsurveillancehasstrengthenedtheabilitytointerveneearlywhenparticulardiseaseorinjurytrendsdemandattention.ThefirstBrightStarexerciseinEgypttookplacetwoyearsafterthe1978CampDavidAccords,andbecameabiennialeventin1983.Battalion-levelDNBIsurveillancewasamongthemanyprocedurespilotedandrefinedduringBrightStariterations.DNBIcategoriesbecamestandardizedatJointChiefsofStafflevelandinclude,amongotherbroadbutrelativelysensitivegroupings,gastrointestinal,respiratory,febrile,dermatological,psychological,andcause-stratifiedtraumaticinjuries.Itshouldbementionedthatanumberofregistriesandspecialstudiessupporttheepidemiologyandsurveillancemission,andviceversa.TheDoDSRcurrentlyhousesnearly40millionserumspecimensinlargewalk-infreezers,andcontinuestogrowbyapproximately2.3millionspecimensperyear.Thisrichrepositoryisaninvaluableresourcetoaddressimportantquestions,suchasthoseexemplifiedbythelistinFigure4.OneexampleofarichdataregistryistheJointTheaterTraumaRegistry,whichissupportedbytheUSArmyResearchInstituteofSurgicalResearchandtheCenterforAMEDDStrategicStudiesatFortSamHouston,Texas.AnotherexampleistheTotalArmyInjuryandHealthOutcomesDatabasemaintainedbytheUSArmyResearchInstituteofEnvironmentalMedicineatNatick,Massachusetts.Finally,effectiveanalysisrequiresdenominators,andthusfeedsfrompersonneldatasystemssuchastheDefenseManpowerDataCenterinMonterrey,CA.INVESTIGATIONProblemsthathavearealorpotentialimpactongroupsofpeopleoranentirepopulationtypicallycometotheattentionofpublichealthleaderseitherbecauseepidemiologistsmonitoringeventsfromacentrallocationseeatrendthatisnotvisibleatanysinglelocation,orbecausecliniciansataparticularlocationnotealocaltrendorindividualcasethatwarrantsanalert.Thelevelofresponse,intermsofbothchainofcommandandnumberofrequiredconsultants,isusuallydictatedbythepredictablebreadthofpotentialhealthimpactandtheperceptionsofleadersandthepublic.Theimmediacyofresponseisdictatedbythelevelofalarmarousedbytheseverity SusceptibilityofmeaslesandrubellaamongUSArmyrecruitsLeishmaniasisserologyinGulfWarveteransPersistenceofantibodytoJapaneseencephalitisvaccineSero-prevalenceofhepatitisA,B,andCinrecruitapplicantsHantavirusinmilitarypersonnelfromfourcornersareaHepatitisCinorthopedicsurgeonsanddentistsRiskoflateHIVsero-conversioninUSsoldiersSerologicevaluationformycoplasmainGulfWarveteransPSAlevelsandPSAvelocityandtheriskofprostatecancerPrevalenceofWestNileVirusinNYmilitaryapplicantsHepatitisCprevalenceandincidenceinUSservicemembersFigure4.Selectionofpreviousstudiesusingthe DoDSerumRepository

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AprilJune200627ofaparticulardisease,orhowquicklyadiseaseorinjuryproblemaffectsanincreasingnumberofpeople,whichinturnisusuallydeterminedbythefrequencyandlatencyofadversehealthoutcomes.Justasdisease,injury,andadverseexposuresurveillanceoccursbothlocallyandcentrally,sotoodoestheinvestigationofunusualdiseasesofimmediatepublichealthimportanceanddiseasesandinjuriesoccurringatahigher-than-expectedincidence.Thisisoneofthemanyrolesofunitorinstallationpreventivemedicinepersonnel.Inamannersimilartoclinicalconsultation,assistancefromhigherlevelsinthemedicalchaincomesintoplaywhenadditionalexpertiseisneededorwhentherearecompetingtasksoccupyinglocalmanpower.Figure5showsthelevelsofPMconsultationinatypicalgarrisonsetting,andalsoimpliesinterorganizationalcoordinationandcommunicationthatmayoccurinresponsetoanoutbreak,includingcivilianliaisonactivities.FormanyyearsEpidemiologicalConsultations(EPICON)wereexecutedfromtheWalterReedArmyInstituteofResearch(WRAIR).WhentheArmyEnvironmentalHygieneAgencytransformedtobecometheCHPPMin1994,anumberofnewmissionswereaddedtoconsolidatecentralsupporttooperationalandgarrisonunitsinseveralpreventivemedicinearenas,includingepidemiologyandhealthpromotion.TheCurrentOperationssectionoftheCHPPMnowreceivesUSArmyMedicalCommand(MEDCOM)ordersandrequeststoinvestigateoutbreaks,clusters,andsentinels.Still,teamsaretaskorganizedsuchthatCHPPMfrequentlypartnerswiththeWRAIRandotherUSArmyMedicalResearchandMaterialCommandorganizations,aswellasotherMEDCOMsubordinatecommands.EPICONsarecomparabletoEpi-AidsconductedbytheCentersforDiseaseControlandPrevention(CDC),and,inasimilarmanner,EPICONsusemilitarypreventivemedicineresidents,justasEpi-AidsutilizeEpidemicIntelligenceServiceofficersandCDCpreventivemedicineresidents.Thisenhancestheintellectualapproachtoproblemsolvingwhilealsoprovidinghands-onteaching,andisnodifferentfromclinicalcasemanagementinhospital-basedgraduatemedicaleducationprograms.TheconceptandproceduresofanEPICONalreadyexistedwhenSpecialMedicalAugmentationResponseTeamswereestablishedwithintheArmyMedicalDepartment.UnderanewconceptaSMART-PM(EPI)*deploymentissynonymouswithEPICON.INTERVENTIONPublichealthinterventionsinmilitarysettingsarenotverydifferentfromthoseintheciviliancontext,andmaytargetsmallgroupsofcontacts,acommunityatlarge,oranentirepopulation.Familiarexamplesincludetheuseofimmunizations,chemoprophylaxis,isolation,quarantine,activecasefindingandaggressivetreatment.Otherequallyimportantkindsofinterventionincluderiskcommunication,healtheducation,equipmentredesign,environmentalcontrolsandreengineering,newandenforcedsafetyprocedures,andnewpolicies,guidelines,procedures,regulations,orlaws.Thegeneralmedicalliteraturefrequentlyincludespapersdescribingpopulation-levelinterventions,butmostofthesearediseaserelated.Sincemeasuresaimedatreducingtheincidenceoftraumaaremoreconcentratedinspecialtyjournals,thefollowingparagraphsbrieflydiscussmilitaryinjurypreventiontoillustratehowinterventionscanderivefromsurveillanceandepidemiologicalinvestigations.Anexampleofaninterventioninvolvingmilitaryequipmentwastheuseofaspecializedanklebracetoreducetheincidenceofankleinjuriesduringairborneoperations.Surveysofinjuriesincurredduringairborneoperationssuggestthat30%to60%involvetheankle.3-7Thesportsmedicineliteraturesuggestedthatfewerankleinjuriesoccurredamongathleteswearinganklebraces.6,9AspecializedparachuteanklebracethatfitoutsidethecombatbootandiseasilydonnedanddoffedwithVelcrostrapswasdeveloped.Arandomizedstudyofairbornetraineesshowedthatduringjumpoperations,thosewearingthisbracehadfewerinversionanklesprainscomparedtothosewhodidnot(0.6versus3.8injuriesper1000jumps,p=0.04).10Later,a3-yearsurveillanceofankleinjuriesinaUSArmyAirborneRangerBattalionshowedthatthosewearingtheanklebracehadsignificantlyfewerankleinjuriescomparedtothosenotwearingthebrace(1.5versus4.5injuries/1000jumps,p<0.01).11Anklebraceswerediscontinuedin2001becauseofthecostandunsubstantiatedanecdotalsuggestionsthattheywerecausingothertypesofinjuries.Astudywasconductedusingasurveillancedatabasethatdemonstratedthattheoddsofhospitalizationforanankleinjurywas2.2(95%CI=1.82.8)timeshigherin*SpecialMedicalAugmentationResponseTeam-Preventive Medicine(Epidemiological)

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28ArmyMedicalDepartmentJournal F i g u r e 5 T h e l e v e l s o f v e r t i c a l a n d l a t e r a l c o o r d i n a t i o n i n p r e v e n t i v e m e d i c i n e c o n s u l t a t i o n i n r e s p o n s e t o a n o u t b r e a k S c h e m a t i c d e m o n s t r a t e s a c t i o n s i n a t y p i c a l g a r r i s o n s e t t i n g w i t h r e p r e s e n t a t i o n s o f t h e i n t e r o r g a n i z a t i o n a l c o o r d i n a t i o n a n d c o m m u n i c a t i o n t h a t m a y o c c u r i n c l u d i n g c i v i l i a n l i a i s o n a c t i v i t i e s ( C h a r t c o u r t e s y o f L T C R o b e r t M o t t W a l t e r R e e d A r m y I n s t i t u t e o f R e s e a r c h ) K e y t o A c r o n y m s C e n t e r s f o r D i s e a s e C o n t r o l a n d P r e v e n t i o n ; U S A r m y C e n t e r f o r H e a l t h P r o m o t i o n a n d P r e v e n t i v e M e d i c i n e E p i d e m i o l o g y a n d D i s e a s e S u r v e i l l a n c e D i r e c t o r a t e ; O f f i c e o f t h e S u r g e o n G e n e r a l P r o p o n e n c y O f f i c e f o r P r e v e n t i v e M e d i c i n e ; A r m y M e d i c a l S u r v e i l l a n c e A c t i v i t y ; M e d i c a l O p e r a t i o n s ; P u b l i c A f f a i r s O f f i c e r ; # M e d i c a l D e p a r t m e n t A c t i v i t y ; * L i a i s o n O f f i c e r ; M o r a l e W e l f a r e R e c r e a t i o n

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AprilJune200629theperiodbeforethebracewasusedand1.7(95%CI=1.22.2)timeshigherafterthebracewasdiscontinued.ThebraceisnowbeingreintegratedintoArmyairborneunitsasaresultofadvocacyeffortsbytheDefenseSafetyOversightCouncil.Anexampleofaninterventionthatinvolvedphysicaltrainingwasconductedduringthe9-weekbasiccombattraining(BCT)cycle.12Previousstudiessuggestedthatreducingrunningmileagecouldreduceinjurieswithoutreducingaerobictrainingeffects,13,14andcrosstrainingwithawidevarietyofexerciseshasbeenrecommendedtoreduceinjuries.15Anewtrainingprogram,incorporatingtheseandotherinjuryreductionprincipleswasdevelopedbytheArmyPhysicalFitnessSchool.Aphase-inofthisprograminBCTallowedacomparisonof2battalions.Onebattalion(n=1284)ranonly17milesandperformedawidevarietyofcrosstrainingexercisesthatincludedcalisthenics,dumbbelldrills,movementdrills,intervaltraining,long-distancerunning,andend-of-trainingstretching.Anotherbattalion(n=1296)conductedtheusualBCTphysicaltrainingprogramconsistingof38milesofrunningandalimitedvarietyofexercises.MenandwomenintheusualBCTprogramwereat1.6and1.5(respectively)timeshigherriskofinjurythanthoseinthereducedrunningandincreasedcrosstrainingprogram.Improvementsin2-mileruntimeswerealmostidenticalinthe2groups.Despitethesuccessoftheprogram,concernwasexpressedbytheArmyleadershipbecauseofthecostandlogisticsassociatedwiththedumbbellportionoftheprogramandpotentialproblemswithsomeoftheexercises.ArmyleadershipalsothoughtthattheArmyfieldmanualonphysicaltraining16containedmanyofthenecessaryprinciplesforenhancingfitnessandreducinginjuries,butinadequatelypresentedhowtheseprinciplesshouldbeappliedinBCT.AnewBCTphysicaltrainingprogramwasdevelopedbytheFitnessSchooltotaketheseconsiderationsintoaccountandasecondprojectwasundertaken.17Onebattalion(BattalionA,n=829)implementedtherevisedphysicaltrainingprogramandwascomparedtoanotherbattalion(BattalionB,n=1138)thatimplementedatraditionalBCTphysicaltrainingprogram.Attheendofthe9-weekBCTcycle,injurysurveillancedatashowedthatmenandwomeninBattalionBwere1.6(95%CI=1.2-2.0)and1.5(95%CI=1.2-1.8)timesmorelikelytobeinjuredcomparedtoBattalionAmenandwomen,respectively.APFTfailureswerealsohigherinBattalionBthaninBattalionA(1.7%vs.3.3%,p=0.03).Thesestudiesdemonstratedthatinjuriescouldbeconsiderablyreducedandfitnessimprovementmaintainedbyspecifictrainingmodificationsandthatsurveillancedatacouldbeusedtocomparegroups.In2003,thecommanderoftheArmyAccessionsCommandmandatedthenewphysicaltrainingprogramforallbasiccombattraining.CONCLUSIONInthecivilianworld,populationmedicineandclinicalmedicinebegantodriftapartahundredyearsago,justafewdecadesafterthegermtheorybegantorevolutionizemedicineasawhole.Whileironic,thisisnotsurprising.Themeanstocombatdiseasegrewoutofresearchlaboratoriesworkinginparalleltodevelopbothweaponsofmassprotection(vaccines)andguns(pharmaceuticalsforindividualtreatment).Thelattergavesuchpowertophysicianswhotreatthesickthattheisolationofpublichealthdepartmentsfromhospitalsandprivateclinicswasinevitable,giventhewayhealthcareevolvedinAmericansociety.Itwouldseemthatthemanagedcareandhealthmaintenancerevolutionshouldhavebroughtmasspreventionandindividualcarebacktogether,butwithbeneficiariesmovingamongsomanycompetingorganizations(bothinsurersandemployers),aparallelfocusonentire,coveredpopulationsisnoteconomical.Thereareexceptionsinthearmamentarium,suchaschildhoodvaccines,butinthosecasestheneedtocomplywithstatelawsisoftentheprimarydriver.WhiletheMilitaryHealthSystemstruggleswithsimilarissuesofcostwhenconsideringthemajorityofbeneficiariesatanypointintime,theactivedutysectorinparticularisaworkforceforwhichhealthprotectionservesboththecorporatecustomer(commanders)andthebeneficiary.Still,thefocusisonpreventionofshort-latencyconditionssuchasacuteinfections,acuteenvironmentalillnesses(eg,duetohotandcoldweatherconditions),andtraumaandevenforthesetheprocessoftargetacquisitionforthosewhomanthebiggunsremainsunacceptablyslow.Asinformationtechnologycontinuestoadvance,andepidemiologicaltoolsintegratewiththetoolsthatfacilitateclinicalcare,theborderbetweenpopulationandindividualcareisbeginningtofade.Liketheelegantfeedbackmechanismsthatcharacterizehumanphysiologyitself,informationsystemswillpermitapopulationhealthandsafetyequilibrium,and,justaswithindividualaccesstocare,theArmedServicesoftheUnitedStatesareleadingtheway.

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30ArmyMedicalDepartmentJournalREFERENCES1.JonesBH.InjuriesintheMilitary.AmJPrevMed.2000;18(35):71-84.2.Bayne-JonesS.TheEvolutionofPreventiveMedicineintheUnitedStatesArmy,1607-1939.Washington,DC:USDeptoftheArmy;1968.3.KirbyN.Parachutinginjuries.ProcRSocMed.1974;67:17-21.4.DavisonD.Areviewofparachutinginjuries.Injury.1990;21:314-316.5.AmamiloSC,SamuelAW,HeskethKT,MoynihanFJ.Aprospectivestudyofparachuteinjuriesincivilians.JBoneJointSurg.1987;69B:17-19.6.LowdenIMR,WetherillMH.Parachuteinjuriesduringtrainingdecents.Injury.1989;20:257-264.7.CraigSC,MorganJ.Parachutinginjurysurveillance,FortBragg,NorthCarolina,May1993toDecember1994.MilMed.1997;162:162-164.8.RovereGD,ClarkeTJ,YatesCS,BurleyK.Retrospectivecomparisonoftapingandanklestabilizersinpreventingankleinjuries.AmJSportsMed.1988;16:228-233.9.SharpeS,KnapikJ,JonesB.Anklebraceseffectivelyreducerecurrenceofanklesprainsinfemalesoccerplayers.JAthletTraining.1997;32:21-24.10.AmorosoPJ,RyanJB,BickleyB,LeitschuhP,TaylorDC,JonesBH.Bracedforimpact:reducingparatrooper'sanklesprainsusingoutside-the-bootbraces.JTrauma.1998;45:575-580.11.ShumacherJT,CreedonJF,PopeRW.Theeffectivenessoftheparachutistanklebraceinreducingankleinjuriesinanairbornerangerbattalion.MilMed.2000;165:944-948.12.KnapikJJ,HauretK,BednarekJM,etal.TheVictoryFitnessProgram.InfluenceoftheUSArmy'semergingphysicalfitnessdoctrineonfitnessandinjuriesinBasicCombatTraining.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;2001.12-MA-5762-01.13.TrankTV,RymanDH,MinagawaRY,TroneDW,ShafferRA.Runningmileage,movementmileage,andfitnessinmaleUSNavyrecruits.MedSciSportsExerc.2001;33:1033-1038.14.ShafferRA.MusculoskeletalInjuryProject.Paperpresentedat:43rdAnnualMeetingoftheAmericanCollegeofSportsMedicine,1996;Cincinnati,OH.15.StamfordB.Cross-training:givingyourselfawhole-bodyworkout.PhysSportsMed.1996;24(9):15-16.16.FieldManual21-20:PhysicalFitnessTraining.Washington,DC:USDeptoftheArmy;1992.17.KnapikJJ,DarakjyS,ScottS,etal.EvaluationoftwoArmyfitnessprograms:theTRADOCStandardizedPhysicalTrainingProgramforBasicCombatTrainingandtheFitnessAssessmentProgram.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;2004.12-HF-5772B-04.AUTHORS COLPetruccelliisDirector,Epidemiology&DiseaseSurveillance,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround,Maryland.DrKnapikisaResearchPhysiologistwiththeDirectorateofEpidemiologyandDiseaseSurveillance,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround,Maryland.

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AprilJune200631INTRODUCTIONThefirstdiscoveryofanarthropod-bornepathogenwasin1893,anditwasquicklyfollowedbynotablesuccessesinthepreventionofyellowfeverandmalariathroughmosquitocontrol.Despitecontinualprogressinthetechnologyofvectorcontrolduringthelastcentury,USmilitaryforcesremainvulnerabletomanyseriousdiseasescausedbypathogenstransmittedbymosquitoes,ticks,andotherarthropodsthatcauseconsiderablemorbidityandmortality.Thehundredsofrecently-returningveteransfromIraqandAfghanistanwhohadcontractedcutaneousleishmaniasistransmittedbysandfliesisatestimonytothisfact.1Otherrecentmilitaryoperationshavealsobeennegativelyimpactedbyarthropod-borneinfections.InSeptember2003,when290MarineswentashoreinLiberiaasmilitaryadvisorstooverseeaciviltransition,80contractedmalaria(28%attackrate).2MalariaremainsasignificantthreatontheKoreanpeninsulaandelsewherethroughoutAsia.Japaneseencephalitisisoneofapproximately100virusesspreadbyinsectsandticksandisasignificantthreattoUSforcesinthePacificregion.Thesearebutafewexamplesofhowarthropod-bornediseasepreventionisatoppriorityforforcehealthprotectionoftheArmy.Inadditiontovector-borneandzoonoticdiseases,biologicalthreatsduringdeploymentsincludebitingandstingingarthropods(fireants,mites/chiggers,scorpions,etc.);vertebrateanimals(rodents,bats,snakes,etc.);andpoisonousplants(e.g.,poisonoakandpoisonsumac).Bitingandstingingarthropodscandegrademissionreadinessandcombateffectivenessevenwhentheydonottransmitdisease.Thesearthropodscancausecasualtiesranginginseverityfromsecondaryinfectionstodeathfromallergicreaction.Annoyancefrompersistentpests,itchingbites,andlossofsleepcanalsoerodemorale.Whetherengagedincombatoperations,ordeployedinsupportofpeacekeepingorhumanitarianrelief,commandersthroughouttheArmyareconcernedaboutvector-bornediseasesandpestthreatsthatcanadverselyaffectthehealthoftheirtroopsandcompromisethesuccessofthemission.Medicalentomologists,asmembersofthepreventivemedicineteam,worktominimizethesethreatsbyapplyingsafepestcontrolwhereitismostneeded.Duringdeployments,thismissionbecomesfocusedonissuesthataffectthehealthofSoldiersandtheirabilitytoaccomplishtheirmission.Pathogenstransmittedbysuchvectorsasmosquitoes,ticks,andmitesaretheprimaryconcernbecauseoutbreaksofassociateddiseasescanoccursuddenlyandaffectthedeployedunit.TheDepartmentofDefense(DoD)andDepartmentoftheArmyrecognizethatvectorcontroltoprotectthehealthandlivesofpersonnelmustbebalancedwiththerisksassociatedwiththeuseofpesticides.Thus,theUSArmyhastakenmanystepstoreducethechancesofunnecessaryexposureofitspersonneltopesticidesthroughasustainedemphasisontheuseofpersonalprotectiveequipment,integratedpestmanagementpractices,theuseofsaferpesticides,VectorControlandPestManagementLTCMustaphaDebboun,MS,USACOLLeonRobert,MS,USAMAJLisaOBrien,MS,USACOLRichardJohnson,MS,USACOLStephenBert,MS,USA Mosquitoes Lice Sandflies Fleas Tsetseflies ChiggerMites Ticks

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32ArmyMedicalDepartmentJournalbetterrecordkeeping,andmaintenanceofacertifiedpesticideapplicatortrainingprogram.TheArmysconstantgoalisfullspectrumdominance(todefeatanyadversaryandcontrolanysituationacrosstherangeofmilitaryoperations)overthethreatofarthropod-bornediseasesanddirectinjury.TheArmydoesthisbyformingpartnershipswithindustryandsupportingacademicresearchtodevelopimproved(moreefficaciousandcosteffective)surveillanceandcontroltechniquesandequipment,aswellasbyidentifyingandimplementingtheuseofoff-the-shelftechnologies.TheArmyalsostrivestoattractandretainhigh-qualitymilitaryandcivilianpersonneltoinitiate,implement,andsupporttheseefforts.Achievementoffullspectrumdominancerequiresinvestmentinthedevelopmentofnewmilitarycapabilities,whichwillleadtomultidimensionalprotectionagainstharmfularthropodsandthediseasestheytransmit.ThepurposeofthisarticleistodescribecurrentmethodologiesandfuturedevelopmentsforvectorcontrolandpestmanagementintheUSArmy.ENTOMOLOGYJOINT/MULTIAGENCYEFFORTMilitaryvectorcontrolandpestmanagementprogramsnotonlymustpreventorcontrolpestsanddiseasevectorsthatadverselyimpactreadinessormilitaryoperations,butmustalsopreventstructure,materiel,orpropertydamage.Thisisahugejoint/multiagencyeffortthatextendsfarbeyondprotectingdeployedservicemembersfromblood-feedingarthropods.Eachofthemilitarycomponentshasitsownmilitaryandcivilianpestmanagementpersonnelemployedtocounterthethreat.ThepestmanagementeffortisguidedbyapplicableExecutiveOrders,Federal,State,andlocalstatutoryandregulatoryrequirementsintheUS.Overseas,USlegalrequirementsaswellasinternationalagreements,StatusofForcesagreements,FinalGoverningStandardsissuedforhostnations,andcriteriaintheOverseasEnvironmentalBaselineGuidanceDocumentmustbefollowed.TheDoDrequiresthatitspersonnelfollowthestrictestpolicies,includingEnvironmentalProtectionAgency(EPA)regulations,relevanttotheareainwhichanoperationisoccurring,eventhoughanoperationmaybeoutsidethejurisdictionofEPA.Animportantexceptionispossibleincaseofneed.TheCommandEntomologistofanoperationcanauthorizetheuseofunregisteredpesticides(suchasthoselocallypurchased)ortheuseofregisteredpesticidesinsitesnotonthelabel.TheArmedForcesPestManagementBoard(AFPMB)isthetri-Serviceorganizationwhichmonitorsandguidesthisinternationaleffort,recommendingpolicyfortheDoD.Militaryandcivilianmembersofthearmedforcesactivelyparticipateinthejointpolicydevelopmentprocess.AdvisorsfromotherfederalagenciessuchastheEPA,theCentersforDiseaseControlandPrevention(CDC),theUSDeptofAgriculture(USDA),USDeptofHomelandSecurity,andothersprovidevaluableadviceduringtheprocess.TheAFPMBworkswiththemilitaryservices,theJointStaff(principallytheJ-4,MedicalReadinessDivision)andthecombatantcommandstoensureDoDpolicyiseffectiveinmeetingthethreattopersonnel,realproperty,andmateriel.ThroughanArmyentomologistassignedasContingencyLiaisonOfficer,theAFPMBensuresthatdeployinganddeployedentomologistshavethetoolstocompletethemission.Incaseswherethetoolsdonotexistorarenolongereffective,researchaimedatdevelopingnewtechnologiesormethodologiesisnecessary.ThisrequirementledtoanewresearchprogramthatbeganinOctober2003,theDeployedWarfighterResearchProgramAgainstInsectsthatCarryDiseasesofMilitaryImportance,orDWFP.ThegoaloftheDWFPistodevelopnewpublichealthinsecticidesandformulations,personalprotectionsystems,andapplicationequipmentforvectorcontrol.NewinsecticidesorformulationsdevelopedunderthisprogramwillrequireEPAregistrationtoensurethelevelofchemicalsafetythatAmericansexpect.TheDefensePestManagementInformationAnalysisCenter(DPMIAC),asubdirectorateoftheAFPMB,analyzesopensourcepestmanagementliterature(refereedpublications,tradejournals,etc.)toprovideinformationonpestissuesfordeploymentsandDoDinstallations.AnArmyentomologistassignedtoDPMIACensuresthatinformationproducts(TechnicalGuides,DiseaseVectorEcologyProfiles,andliteraturesearches)meettherequirementsofArmycustomersaroundtheworld.InformationrelevantfordeploymentsisprovidedtotheArmedForcesMedicalIntelligenceCenter(AFMIC)forintegrationwiththeirdata.AFMICthenproducesintelligenceproductssuchastheAFMICMedicalEnvironmentalDiseaseIntelligenceandCountermeasures(MEDIC)CD,InfectiousDiseaseRiskAssessments,andothers.TheUSArmyVeterinaryCommandoftencollaboratesonmanagementissuesinvolvingvertebratepestssuchasferalanimalsandrabiescontrol.

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AprilJune200633TheU.S.ArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)alsohasanimportantEntomologicalSciencesProgram(ESP)withamissiontomaximizetheabilityforUSArmyunitsandinstallationstoprotecttheSoldierfromthehealththreatposedbyvector-bornediseaseandmedicallyimportantpestsandtominimizetheadverseeffectsofpesticides.Forexample,underthedirectionandleadershipofESP,theWestNilevirus(WNV)SurveillanceProgramwasagoodexampleofamultiagencyeffortinpestmanagement.FollowingtheemergenceofWNVintheUSinthelatesummerof1999,theArmySurgeonGeneraldirectedthecreationandimplementationofaWNVSurveillanceandControlProgramforArmyinstallations.ThroughcollaborationwiththeCDC,stateandlocalhealthdepartments,theUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM),theUSArmyVeterinaryCommand,andothers,militaryinstallationswereabletousemosquitosurveillanceandcontrol,deadbirdsurveillance,andhumancasemonitoringtominimizetheriskofWNVtopersonnelonArmyinstallations.Navy,Marine,andAirForceinstallationsconductedsimilarprogramswithmutualinteractionsonpestmanagement-relatedissuesdiscussedbyanadhocWNVcommitteeoftheAFPMB.PERSONALPROTECTIONVector-bornediseasesandassociateddiscomfortcausedbybitingarthropodscanbelargelypreventedwithproperuseofpersonalprotectivemeasures(PPMs)byindividualSoldiers.Personalprotectivemeasuresincludearthropodrepellents,clothingimpregnants,andequipmentandtechniqueswhich,whenappropriatelyapplied,willpreservethefightingstrengthofthetroops.HistoryandMilitarySignificanceOf80diseasesofmilitaryimportance,overtwo-thirdsarecausedbypathogenstransmittedbyarthropods.3Inaddition,arthropodscaninflictseverephysical,psychological,andeconomicstressesthatthreatenthemilitarymission.Forexample,arthropodbitescanbepainfullydistractingandcanleadtosecondaryinfections,dermatitis,orallergicreactions.DuringtheVietnamconflict,theirritationcausedbyblisterbeetles(familyMeloidae)wasamajorsourceofcasualtiesinsomelocations.Intherecentmilitaryactions,pestcontrolwasnecessarytostopanoutbreakofdermatitiscausedbyadifferentkindofbeetle(Paederusrovebeetles)inPakistan.Ifthereisonelessontobelearnedfromthemedicalmanagementofdiseasecasualtiesfromallpastwars,itisthat,duringpeacetimeweshouldprepareourresponsetoanyvector-bornediseaseswecouldencounterduringfutureoperations.Duetothelackofeffectivevaccinesorchemoprophylaxisformanyvector-bornediseases,properuseofPPMsmayprovidetheonlyavailableprotectionfromarthropod-bornediseases.ProperuseofPPMsbyallSoldiersatriskofvector-bornediseasesiscriticalforreducingtheoccurrenceofdiseaseornonbattleinjuriesincurrentconflicts.RepellentsareonecommonlyusedformofPPM.Theyprovidethecommanderwithaquickandinexpensivemeasuretoprotecttheforceinanymilitarysituation,nomatterhowquicklytheunitiscalledintoaction.Theycanbeappliedeffectivelytopreventanyarthropod-bornedisease,whetherornotsurveillancehasidentifiedthepathogen.Repellentsareoftentheonlymeansofprotectionagainstarthropod-bornediseasesincombatenvironmentswhenvectorcontrolmeasuresarenotpossibleorwhenthespeedofmilitarydevelopmentspreventstheuseofchemoprophylaxisorvaccines.Inaddition,commanderswillbeabletominimizeincidenceofanyvector-bornedisease,providingatacticaladvantageagainstanunprotectedenemyforcewhichdoesnothavethebenefitofaneffective,long-lastingarthropodrepellent.TopicalRepellentsTheUSmilitaryhasbeenamajorcustomerforthedevelopmentofrepellentsbeginningin1942whenitwasrecognizedthatarthropod-bornediseasewasanimportantsourceofcasualtiesduringWorldWarII.Thisprogramproducedaseriesofactiveingredients.Thecurrentmilitaryrepellent,N,N-diethyl-3-methyl-benzamide(deet),wasfirstmarketedcommerciallyin1956.Earlyformulationswereeffective,buthaddrawbackstheapplicationlastedforonly1or2hoursinwarmandhumidconditions,feltveryoilyontheskin,hadanobjectionableodor,andwasastrongplasticizer(itdissolvedsomekindsofplastics).4Asaresult,troopsdidnotliketouseit,andmostdidnot.Over62%of1,500SoldierswhorespondedtoaquestionnaireurgedtheArmytogetabetterrepellent.In1990,thestandardmilitarytopicalarthropodrepellentwaschangedtoasustained-release,polymerformulationcontaining35%deetanddubbedtheExtendedDurationTopicalInsectandArthropod

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34ArmyMedicalDepartmentJournalRepellent(EDTIAR).ThisproductwasdevelopedbytheDoDincollaborationwiththe3MCorporationfollowingextensivetestingofexperimentalproductsbytheLettermanArmyInstituteofResearch.Thesearchforbetterrepellentsisstillgoingon.In1999,theDepartmentoftheArmyapprovedaScienceandTechnologyObjective(STO)fordevelopmentofanewtopicalstandardmilitaryinsectrepellentincollaborationwiththeUSDAsChemicalsAffectingInsectBehaviorLaboratoryinBeltsville,MD.Tosupportthiswork,theDepartmentofEntomologyattheWalterReedArmyInstituteofResearch(WRAIR)developednewmethodsnewstatistics,computermodelingofrepellentactivity,5invivotesting,6andinvitrotesting7forrepellentevaluationthatexpandedontheexcellentworkatUSDA.TheSTOwascompletedin2005,producinganewcandidateactiveingredient,(1S,2S)-methylpiperidinyl-3-cyclohexene-1-carboxamide(SS220)innewformulationsthatareeasiertousethantheEDTIAR.Inadditiontothedevelopmentofnewrepellentchemistries,anewformulationofdeetwasdeveloped.InordertoprovideSoldiersandMarinesinatacticalenvironmentwithmoreconvenientprotectionfrombitingarthropods,theWRAIRRepellentProgramcollaboratedwithIguanaLLCtoproduceanew,improvedformulationofcamouflagefacepaintinsectrepellentwith30%deet.Theobjectiveintheevaluationofanyrepellenttestishowitperformsinthefield.With5overseaslaboratories(ArmedForcesResearchInstituteofMedicalSciences,Bangkok,Thailand;USArmyMedicalResearchUnit-Kenya,Nairobi;NavalMedicalResearchCenterDetachment,Lima,Peru;NavalMedicalResearchUnit-3,Cairo,Egypt;andNavalMedicalResearchUnit2,Jakarta,Indonesia)andcollaborationwiththeAustralianArmyMalariaInstitute,theUSmilitaryisinanexcellentpositiontotestrepellentsagainstvectorsofmanydiseasecausingpathogens.RepellentsManyofthepathogensofmilitaryimportancearevectoredbyticks,chiggermites,fleas,andbodylice.Allofthesevectorshaveclosecontacttoclothingwhentheybite,makingthedevelopmentofrepellentstobeappliedtoclothingalogicaldevelopment.Aneffectiveclothingrepellentbasedonthesyntheticpyrethroid,permethrinwasfieldedin1991andisstillinusetodayasthestandardmilitaryclothingrepellent.4Currently,militarypersonnelusepermethrintorepelandkillarthropodsthatlandonmanykindsoftreatedsurfaces,includingfielduniforms,tents,bednets,andhelmetcovers.ClothingandEquipmentAlthoughoftenneglected,oneofthemostpracticalmeansofreducingarthropodbitesistheproperwearingoftheBDU/ACU(battledressuniform/Armycombatuniform).MostarthropodscannotbitethroughtheBDU/ACUmaterialunlessitistightlystretchedagainsttheskin.Therefore,Soldiersmustwearlooselyfitteduniformsandminimizetheamountofbareskinthatisexposedtoblood-suckingarthropods.4Fieldobservationsontherelationshipbetweenclothingandlocalizationofcutaneousleishmaniasislesions(atthesiteofasandflybite)haveconfirmedtheimportanceofproperclothingwearinpersonalprotection.8MosquitoBedNetThemosquitobednetisafinelywoven,nyloncanopythatcanbeusedwiththefoldingcot,hammock,steelbed,orshelterhalf-tent.Forallapplications,thebednetmustbesupportedandtuckedintopreventcontactwiththeoccupantsbodywhilesleepingtopreventmosquitoesandotherbitingarthropodsfrombitingthroughthemesh.Standardmilitarypermethrinandinsecticidespacespray(2%dAerosolSprayCan 2-GallonSprayer Factory-treated IDAKit Four(4)MilitaryProducts NOTE:AllrepellentsareClassIIIstockitems.

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AprilJune200635phenothrin)canbesprayedonthemeshoroninsectsthataretrappedinsidethenet.DetailsareintheArmedForcesPestManagementBoards(AFPMB)TechnicalGuide36.4ThenewSelf-SupportingLow-ProfileBedNetcanbecarriedinsidethebackpackorbetweenthebackpackandframe.Ithasabuilt-inframedesignedforsinglestep,"pop-up"assembly.Permethrin-impregnatedtightweavemeshprovidesincreasedprotectionagainstverysmallbitingarthropodssuchassandflies.Thebednetmaybeuseddirectlyontheground.Infraredsignature,forestcamouflagepatternandcarryingcapacityarecompatiblewithmilitaryrequirements.Thus,thenewbednetislessvisibletotheenemy,lighterinweight(2lbs),andeasiertosetupandtakedownthantheolderbednet.DoDInsectRepellentSystemTheDoDInsectRepellentSystemisavailableforusebyallleadersandtroopstopreventarthropod-bornepathogensthatcausediseasessuchasmalaria,leishmaniasis,scrubtyphus,WestNilefever,andLymedisease.Whenusedproperly,theDoDInsectRepellentSystemwillpreventdisease,pain,andtheannoyancecausedbybitesofinsectssuchasmosquitoes,sandflies,andotherarthropodssuchasticksandchiggers.Thesystemconsistsofthreecomponentspermethrinonuniforms(andbednets),deetonexposedskin,andproperwearoftheuniformandiscriticaltotheArmyMedicalRegimentsmottotoConservetheFightingStrength.ItisamissionessentialtasklocatedinSTP-21-1-SMCTSoldiersManualofCommonTaskTesting,SkillLevel1dated11Oct2005.ThissystemisaDoDPolicythateverySoldier,Sailor,Airman,andMarine,needtostrictlyfollow.DetailsareintheAFPMBTechnicalGuide364andintheUSACHPPMfactsheetontheDoDInsectRepellentSystem9andattheArmyMedicalDepartmentCenterandSchooldeploymenttrainingportal.10ImmunizationsandChemoprophylaxisBothimmunizationsandchemoprophylacticmeasuresareconsideredpersonalprotectivemeasuresalthoughtheyarenotcontrolledbytheindividualSoldier.Chemoprophylaxisisavailableforsomeoftheprotozoan(malaria)andbacterial(scrubtyphus)pathogenstransmittedbyarthropods.Vaccinesareroutinelyavailableforonlyafewoftheviralpathogens(yellowfevervirus,Japaneseencephalitisvirus)andareavailableonanexperimentaluseprotocolforafewothers(Venezuelanequineencephalitisvirus,RiftValleyfevervirus).Evenwhenappropriatechemoprophylaxisorvaccinationisavailableforthediseaseofgreatestconcern,theiruseentailsconsiderablemedicalmanagement.Whenriskisunknownorconsideredtobelow,personalprotectionmaybetheappropriatestrategyforprevention.Therefore,theproperuseofotherpersonalprotectivemeasuresdescribedearlierofferthemostpracticalmeansofinterruptingandpreventingarthropod-bornediseasetransmission. ?ODGreen(Camouflage)NSN3740-01-516-4415?CoyoteBrownNSN3740-01-518-7310 Light-weight,self-supporting,POP-UPbednet Thepop-upbednetisfactory-treatedwithpermethrinandhasmuchfinermeshthanthestandardmilitarybednet. 1 2 3 ItsDoDPolicy Itsabasictrainingtask Itscriticalforyourhealth

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36ArmyMedicalDepartmentJournalInsummary,thereare3requiredcomponentsforeffectivepersonalprotection.First,themeasureitselfmustbeefficaciouswhenproperlyused.Second,thedevelopmentandcontinualmaintenanceofawell-definededucationprogramisofparamountimportance.EveryenlistedSoldier,everyofficer,andespeciallyeverycommandermustbeinformedabouttheimportanceofpersonalprotectivemeasuresforreducingtheoccurrenceofdiseasecausedbyarthropod-bornepathogens.FieldsanitationteamsatthecompanylevelcanservethecommanderbyeducatingSoldiersandensuringadequatepersonalprotectivesuppliesaremaintainedandusedproperly.Finally,enforcementofPPMissometimesappropriatetoassureindividualcompliance.Disciplineinusingprovenpersonalprotectivemeasuresmustbereinforcedthroughcommandemphasisandinvolvement.TheindividualSoldieristhemostimportantelementinanycombatsystem.Protectionofhis/herhealthisabsolutelycriticaltomaintenanceofahighstateofcombatreadiness.Medicaladvisorshavethejobofsupportingthecommanderbyprovidingsoundtechnicaladviceandtraininginthepreventionofarthropod-bornediseases.Thus,itisimperativethatDoDleadersatalllevelsunderstandandendorsetheneedandtheuseofthesepersonalprotectivemeasures.SURVEILLANCEDiseasevectorandpestsurveillanceisdesignedto:1.measuretherelativepopulationlevelsofknownpeststodeterminewhenandwheretobeginspecificmanagementtechniques;2.detectinvasionsofnewandpotentiallyimportantvectorsandpests;3.detectbreedingsitesthatcanbeeliminated;and4.measuretheeffectivenessofpreviousmanagementefforts.TheArmyhas2majorgroupsinvolvedinpestsurveillanceandmanagement.Onegroupprimarilyresearchesmedicalaspectsofarthropod-bornepathogens,conductsmedicalpersonneltraininginthesediseases,andprovidespestmanagementincontingencyoperations.Theothergroupisthefacilitiesengineeringelementresponsibleforprotectingpropertyandmaterielsubjecttopestinfestationordestruction,includingmostpestmanagementoperationsatDoDinstallations.Cooperationbetweenthesetwoelementsisessentialtoensurecomplete,efficientprotectionofDoDpersonnel,property,andmaterial.Preventionofvector-bornediseasesthroughtimelysurveillanceandsubsequentintegratedpestmanagement(IPM)reliesoneffectivedecision-making.Decision-makingtoolsincludeprotocolsfordecidingtheneedforsomemanagementactionbasedonanassessmentofthepestpopulationanditspotentialforthetransmissionofvector-bornediseasetohumans.Monitoringanduseofactionthresholdsarestandardpracticeinmilitarypreventivemedicine.Theseprotocols(alsoknownascontroldecisionrules)consistofstandardizedproceduresforassessingthedensityofpestpopulationsandanactionthreshold,inthiscasethelowestpopulationdensityaboveanacceptablebaselinevaluethatwillcausenuisanceand/ordisease.Thus,carefullyplannedsurveillanceplaysacriticalroleinassessingvector-bornediseasethreatsbecausetheinformationgainedcaninfluencedecisionsontheuseofmedicalpreventiveinterventions,suchaschemoprophylaxis,andpesticideusage.OnerecentexampleofasuccessinthisareawastherolemosquitoandmalariaparasitesurveillanceplayedtohelpshapeanimprovedtheatermalariachemoprophylaxisprogramforOperationsIraqiFreedom(OIF)andEnduringFreedom.Malariachemoprophylaxiswassubstantiallyreducedinareaswithnoactivetransmission,thusloweringcosts,limitinglogisticsconcerns,anddiminishingundesirablesideeffectsofchemoprophylacticdrugs.Flyinginsectvectorsofdiseasesuchasmosquitoesandsandfliescurrentlyposethegreatestthreattodeployedarmedforces.StandardizedflyinginsecttrappingprogramsuseCDClighttraps(small,batteryoperatedtrapswithflashlight-likebulbsandoftensupplementedwithdryiceasanattractant)duringthehoursofdarkness.CollectedmosquitoescanbetestedimmediatelyinthefieldusingtheVecTestkit(MicrogenicsCorp.,Fremont,CA,800-232-3342)andresultsareobtainedwithin15minutes.TheVecTestisanantigenpanelassaythatusesarapiddetectiondipstickdesignedtospecificallytestforpresenceofmalariaparasitesinmosquitoes.ThetestkitemploysawickingdipstickassaythatdetectsPlasmodiumfalciparumandP.vivax(variants210&247)inpoolsofupto10anophelinemosquitoes.TheMalariaVecTestKitusesspecificmonoclonalantibodiestargetingthecircumsporozoiteantigensfoundonthe

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AprilJune200637surfaceofthePlasmodiumparasites.Thisinnovative,effective,andinexpensivetestwasdevelopedcooperativelybyWRAIRandMedicalAnalysisSystems,Inc.DuringtheearlystagesofOIF,Soldiercomplaintsofsandflybiteswerehigh,aswastheriskofcontractingleishmaniasis.ArmyentomologistsworkingatTallilAirBasein2003collectedover21,000femalephlebotominesandfliesandsentthemtoWRAIRwheretheyweretestedforthepresenceofleishmaniaparasitesusingfluorogenicPCR(polymerasechainreaction)assay.11Theseentomologistsquicklycalculatedthattheminimumfieldinfectionratewas1.58%.Bymappingoutthetemporalandgeographicdistributionofallsandfliesandinfectedsandflies,theteamwasabletofocuscontroleffortsinareasthatwereathighestriskforleishmaniasis.AdiverseteamofUSArmy,AirForce,andNavyentomologists,alongwithcolleaguesfromvariouscoalitionforces(British,Italian,Dutch,andKorean),andpestcontrolcontractorsimplementedanaggressiveleishmaniasiscontrolplan.Accuratevectoridentificationandknowledgeofvectorbiologyareessentialforarthropod-bornediseaseriskassessmentandfordevelopmentofappropriatestrategiesforvectorsuppression,arthropod-bornediseasereduction,andvaccineanddrugdevelopment.Therearehundredsofspecieswithvaryingcapabilitiesoftransmittingdiseases,dependingonfactorssuchasphysiologicalcompatibilitywiththediseaseorganism,hostspeciespreference,andfeedingtimesandlocations.Potentialvectorsmustbeidentifiedatleasttothespeciesleveltoprovidethemostusefulinformation.InsectidentificationisgreatlyassistedthroughthereachbackcapabilitiesprovidedbytheWalterReedBiosystematicsUnit,partoftheWRAIR,locatedattheMuseumSupportCenteroftheSmithsonianInstitutioninSuitland,MD.Thisuniquenationalresourceprovidesonlinemosquitoandsandflyidentificationkeys,laboratoryandfieldprotocols,high-resolutionimagesofmosquitomorphology,andmanyotheronlineproductstoassistmilitaryentomologistsdeployedaroundtheworldtocorrectlyandquicklyidentifyarthropodvectorsofdisease.Newandinnovativesurveillancetechniquesarecurrentlybeingdevelopedbymilitaryentomologists.TheWRAIR,inpartnershipwiththeAmericanBiophysicsCorp.,iscurrentlyevaluatingnewandinnovativeinsectsurveillancetoolsandcontroldevices.EntomologistsatWRAIRandtheUniformedServicesUniversityoftheHealthSciencesaredevelopingremotesensingcapabilitiesthatcanbeappliedindiseasevectorsurveillance.Wehaveallbecomeaccustomedtothe"birds-eye"viewoftheearthprovidedbyphotographsandimagesacquiredfromaircraftaswellasfrommannedandunmannedspacecraft.Itisthisbirds-eyeviewthatmilitaryentomologistsplantoexploittocollectmoreinformativeandpredictiveinsectsurveillancedata.CONTROLTheDoDpestmanagementcommunityisfirmlycommittedtotheprinciplesofIPMasstatedinDoDInstruction4150.7.12Integratedpestmanagementdescribesmanyapproachestopestcontrolincludingnon-chemicalactivitiessuchassanitation,habitatmodification,anddevelopmentofsurveillanceprogramstospecificallytargetpestlocationsandactivitytimes.UseofIPMmustnotcompromisetheeffectivenessofcontrolandmustbetailoredtobestaddressthespecificneedsofeachpestordiseasevectorproblem.TheArmyrecognizesthatpesticidesareindispensablemanagementtools,andtakesseriouslytheresponsibilityfortheirsafeandeffectiveuse.AspartofanyIPMprogram,whenchoosingtousechemicalcontroltools,pestmanagersaredirectedtoselecttheleasthazardouspesticidesthatwillstillprovideacceptableresults.Forexample,pesticidesintheorganophosphateandcarbamatechemicalclassesarestillusedifspecificconditionswarrant,buteffectivesubstitutessuchasnewergenerationpyrethrinsorinsectgrowthregulatorsarepreferredchoices.Inaddition,sincetheDoDMeasuresofMeritwereinstitutedoveradecadeagowiththeonestatedgoalofa50%reductioninpesticideusebytheyear2000,theentireexistingpesticidelisthasbeencarefullyevaluatedandupdated.Whenpossible,lowerapplicationratepesticidesweresubstitutedforhigherrateproductsandlowertoxicitychemicalswereaddedtotheinventory.This,inadditiontoaDoDculturethatemphasizesIPM,hasenabledtheDoDtoachievea61%reductioninpesticideuseby2006.sincetheprograminception,whilestillmaintainingappropriatelevelsofpestanddiseasevectorcontrol.TheDoDhasexceededallitspesticideusereductiongoals,andwillcontinuetofocusonfurtherreductionswhereverpossible.TheDefenseLogisticAgencyregularlyupdatesthenationalstocklisttoreflectthisgoal.However,thiseffortsucceedsonlyasnew,effective,andlesstoxicactiveingredientsaredevelopedandregisteredforuse

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38ArmyMedicalDepartmentJournalbytheEPA,aslowandextremelycostlyendeavorforpesticidemanufacturers.Whensuchproductsarebroughttothemarket,theAFPMBmakeseveryefforttoevaluatetheirpotentialforusebyDoDcomponentsandtoaddthemasneededtothestocklist.Examplesthatappearonthecurrentstocklistincludeinsectgrowthregulators,suchasfenoxycarbandmethoprene,andmicrobialpesticides,suchasBacillusthuringiensisandspinosad.MembersoftheAFPMBarealsoperiodicallyapproachedbyvendorsattemptingtosellproductstotheDoDwhichtheylabelasnaturalorotherwisehavinglow/notoxicity.Unfortunately,inmostofthesecases,thedatasupportingtheseproductsiseitherinsufficientornonexistent,particularlyiftheproductdoesnotrequireEPAregistration.Nevertheless,iftheseproductsmeetthemilitarysrigorousefficacyrequirements,theycouldbesupportedbyprofessionalpestmanagersandaddedtothenationalstocklist.UseoflesstoxicandmoreeffectivepesticidesisobviouslyadvantageoustotheDoDPestManagementProgramtoprotecthumanhealthandtheenvironment.PestmanagementprofessionalsintheDoDalsorecognizetheneedtomaintainasufficientlydiverseinventoryofpesticidestodelaytheonsetofresistance,whichmakescertainpesticidesineffectiveandthreatensthemilitarysabilitytopreventdiseases.Toaddresstheseissues,DoDpestmanagementprofessionals,inconjunctionwithrepresentativesfromtheCDC,NationalInstitutesofHealth,USAgencyforInternationalDevelopment,USDA,privateindustry,andprofessionalpestcontrolorganizations,activelyseekmoreeffectiveandlesstoxicorenvironmentallyhazardouspesticidesthatwillstillmeetdiversemilitarypestmanagementneeds.Thisgroupofconcernedstakeholdersandpesticideusersrecognizesthefactthatsomepesticidesarebeingremovedfromtheinventorynotonlyduetoconcernsabouthumanexposuresandenvironmentalsafety,butalsoduetodevelopmentofresistancetoinsecticidesandlackofeconomicincentivestodevelopandmaintainproductsusedfordiseasevectorcontrol.Thegroupiscurrentlyidentifyingstrategiestopromoteandsupportthedevelopmentofmuch-needednewproducts.TheDoDviewscarefulscreeningandselectionofthepesticidesauthorizedforuseasonecrucialcomponentofanyeffectiveIPMprogram.Anothercrucialcomponentisthetypeofpestmanagementequipmentandmethodologyusedinapplyingpesticides.Inadditiontousingthemosteffectiveandefficientcommerciallyproducedpesticideapplicationequipment,themilitaryservicesconductresearch,eitherintramurallyorcollaboratively,withUSDAtodevelopneworimproveexistingpesticideapplicationtechnologiesforincreasingefficacyofpesticidedispersal,and/orreducingtheamountofpesticideneededforeffectivecontrol.TheDWFPsuppliescompetitivefundingspecificallyforresearchrelatingtopesticidetechnologies.Ofparticularpromiseiscurrentmilitaryresearchontheintegrationofglobalpositioningsystems,newhigh-pressuresystemsforC-130aircraftaerialpesticideapplication,andtheevaluationofunmannedaerialvehiclesforpesticideapplicationinhard-to-reachordangerousareas.TheAFPMBPesticideandEquipmentCommitteestaketheleadonidentifyingandrecommendingnewproductsandequipmentforinclusiononthenationalstocklist.ThisprocesssupportstheongoingeffortswithintheDoDtoprovideeffectivepestandvectorcontrolinthesafestpossiblemanner.SUMMARYEntomologicalhazards,includingvector-bornediseases,stingingandbitingarthropods,andharmfulanimalsandplantsremainasignificantthreattoUSmilitaryforcesbothathomeandabroad.Militaryentomologistscontinuetousesafe,effective,establishedmethodsofsurveillanceandcontrolwhilecontinuingtodevelopnew,innovative,safer,andmoreeffectivemethods.ThisisdueinlargeparttothesynergythatresultsfromjointeffortsbetweentheArmy,AirForce,andNavythroughthecontinuedcoordinationoftheAFPMB.Partneringwithothergovernmentagencies(USDA),industry,anduniversitieshasalsostimulatedthedevelopmentandimplementationofnewandmoreeffectivetechnologiesthatcanbequicklydeliveredtofieldforces.AlloftheseactivitiesarecontinuallybringingmilitaryentomologyclosertothegoaloffullspectrumdominanceoverharmfularthropodsandnoxiousanimalsandplantsthatotherwisewouldcauseUSforcestosuffermorbidityandmortality.ACKNOWLEDGMENT TheauthorsthankDrEdEvansandSandyEvansfromtheEntomologicalSciencesProgramatUSACHPPMforprovidingphotosandeditorialsupport,andCOL(Ret)DanielStrickman,DrRichRobbins,andZiaMehrforhelpfulcommentsandreviewofthisarticle.

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AprilJune200639REFERENCES1.AronsonN,AnanthakrishmanM,BernsteinW,etal.Update:CutaneousleishmaniasisinU.S.militarypersonnelSouthwest/CentralAsia,20022004.JAMA.2004;291:2188.2.USNavyEnvironmentalHealthCenter.MalariaoutbreakamongmembersofJTFLiberiaConsensusConferenceReport.2003.Availableonlineat:http://www-nehc.med.navy.mil/downloads/prevmed/JFTMalaria.pdf.3.HandbookofDiseasesofMilitaryImportance.Washington,DC:USDeptofDefense,DefenseIntelligenceAgency;1982.4.TechnicalGuideNo.36,PersonalProtectiveMeasuresAgainstInsectsandOtherArthropodsofMilitarySignificance.Washington,DC:USDeptofDefense,ArmedForcesPestManagementBoard;1996.Availableonlineat:http://www.afpmb.org/coweb/guidance_targets/ppms/TG36/TG36.htm5.MaD,BhattacharjeeAK,GuptaRK,CarleJM.Predictingmosquitorepellentpotencyofn.n-diethyl-m-toluamide(DEET)analogsfrommolecularelectronicproperties.AmJTropMedHyg.1999;60:1-6.6.KlunJ,DebbounM.Anewmoduleforquantitativeevaluationofrepellentefficacyusinghumansubjects.JMedEntomol.2000;37:177-181.7.KlunJ,KramerM,DebbounM.Anewinvitrobioassaysystemfordiscoveryofnovelhuman-usemosquitorepellents.JAmMosqContAssoc.2005;21:64-70.8.DedetJP,EsterreP,PradinaudR.IndividualclothingprophylaxisofcutaneousleishmaniasisintheAmazonianarea.TransRoyalSocTropMedHyg.1987;81:7489.USArmyCenterforHealthPromotion&PreventiveMedicine.DoDinsectrepellentsystem.Availableat:http://chppm-www.apgea.army.mil/documents/DoDInsectRepellentSys.pdf10.USArmyMedicalCommandCenter&School.Deploymentrelevantwebsites.Availableat:http://www.cs.amedd.army.mil/deployment2.aspx#11.BerteSB.USArmyentomologysupporttodeployedforces.AmerEntomol.2005;51;No.4:208-217.12.DoDInstruction4150.7,DoDPestManagementProgram.Washington,DC:USDeptofDefense;April22,1996.AUTHORS LTCDebbounistheChiefofMedicalZoologyBranchandDeputyChiefoftheDepartmentofPreventiveHealthServices,AcademyofHealthSciences,USArmyMedicalDepartmentCenter&School,FortSamHouston,Texas.COLLeonRobertisanAssociateProfessor,DepartmentofChemistryandLifeScience,USMilitaryAcademy,WestPoint,NewYork.MAJOBrienistheChief,DefensePestManagementInformationAnalysisCenter,ArmedForcesPestManagementBoard,Washington,DC.COLJohnsonistheDirector,ArmedForcesPestManagementBoard,OfficeoftheDeputyUnderSecretaryofDefense(InstallationsandEnvironment),Washington,DC.COLBerte,aformerMedicalEntomologyConsultanttotheSurgeonGeneraloftheArmy,nowservesastheJointProjectManageroftheChemicalBiologicalMedicalSystemsProjectManagementOffice,FortDetrick,Maryland. Aedesalbopictus(AsianTigerMosquito) Phlebotomuspapatasi(SandFly)

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40ArmyMedicalDepartmentJournalFieldPreventiveMedicinereferstoallactionsthatprovidecommanderswithafitandhealthydeployableforce,sustainthehealthandfitnessoftheforceduringamilitaryoperation,andpreventcasualtiescausedbydiseaseandnonbattleinjury(DNBI).PreventingorreducingDNBIallowsthewarfightertofocusmanpowerandresourcesonmissionaccomplishmentandallowsmedicalassetstofocusontreatingcombatrelatedinjuries.ActionsthataffectFieldPreventiveMedicineoccurpriorto,during,andafterdeployment,andinvolvecommandresponsibility,unitleadershipstandardsandenforcement,individualactions,unitlevelsupportthroughtheFieldSanitationTeam(FLDSANTM),anddirectandgeneralsupportfrompreventivemedicinepersonnel.Thesefirst4componentscommander,unitleaders,individualSoldiers,FLDSANTMaretheprimaryresourcesformaintainingthehealthofthecommandandpreventingDNBI.TheArmyMedicalDepartment,throughitspreventivemedicinepersonnel,providessupportingservicesasaresourceforthecommandershealthprogram.PERSONNELRESPONSIBILITIESCommandersThecommanderistheauthorityforactionsthatoccurwithintheunitandis,therefore,responsibleforthehealthandwelfareoftheunit,andtherebythepreventionofDNBI.Thecommanderprovidesthetime,training,resources,andemphasisneededtoimplementaDNBIpreventionprogram.Thecommandersetsthestandards,leadsbyexample,andensurestheestablishmentofdevicesorpracticesthatpromoteunitorcollectivePreventiveMedicineMeasures(PMM).Theseincludelatrines,handwashingstations,shavingareas,showers,arthropodandrodentcontrol,andfoodandwatersanitationandqualityissues.ThecommanderisresponsibleforensuringthatFLDSANTMsuppliesareon-handandtakenwiththeunitwhenitdeploys.UnitLeadersUnitleadersmustsupportthecommandshealthprogramandensurethatallunitmembersadheretocommandpoliciesandprocedures.UnitleadersmustbeknowledgeableonhealthissuesandtheapplicationofPMM,whicharethemethodsusedtopreventandmitigateDNBI.SoldiersSoldiersatalllevelsareresponsibleforimplementingindividualPMM.Theseindividualtasksmaybeverybasic,eg,handwashing,bathing,changingsocks,andbrushingteeth.Ortheymaybemorecomplex,eg,usinginsectrepellentsandconsumingfoodandwateronlyfromapprovedsources.UtilizingPMMtakestimeandresources,butprimarilydiscipline.MostSoldiersknowhowtoimplementthemajorityofPMM,butmaynotdoitbecauseoftheperceivedinconvenience.FieldSanitationTeamsToassistthecommandinmitigationofDNBIthroughtheuseofunit-levelPMM,eachcompanysizedunitisrequired,perArmyRegulation40-5,1toestablishandequipatwo-personFLDSANTM.Thisteamiscomposedofonenoncommissionedofficerandonejuniorenlisted.Forunitsassignedaunithealthcarespecialist(ie,medic),thehealthcarespecialistshouldbeoneofthesemembers.Personnelselectedforthisadditionaldutymustbehighlycapableindividuals,possessaboveaverageleadershipskills,andshouldbeexpectedtostaywiththeunitforatleast6monthsafterbeingtrained.Preventivemedicinepersonnelcertifyeachteammemberthrougha40-hourcourseonfieldsanitation.ThiscertificationshouldtakeplaceFieldPreventiveMedicine:ChallengesfortheFutureLTCWilliamJ.Sames,MS,USALTCThomasC.Delk,MS,USAMAJPaulJ.Lyons,MS,USANote:ThedoctrineoffieldpreventivemedicineservicesdiscussedinthispaperisdelineatedinDepartmentoftheArmy FieldManual4-02.17,PreventiveMedicineServices.

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AprilJune200641whileingarrison,butpreventivemedicinepersonnelcanprovidetherequiredtrainingwhiledeployed.FieldSanitationTeamsemploytheinformationcontainedinFieldManual(FM)4-25.12,2andFM21-10.3Currentlythesemanualsarebeingrevisedandcombinedintoonecomprehensivedocument.*TheFLDSANTMmonitorstheuseofindividualandunitPMM,andprovidesguidanceanddirectionontheconstructionofunitleveldevicesforimplementingPMM.Theinformationgathered,alongwiththeirrecommendationsforenhancingindividualandunitPMM,isreportedtothecommanderandunitleaders.Asnecessary,thecommanderdecidesonacourseofactionforcorrectingorenhancingPMM,andunitleadersimplementthisplan.Ifaworkdetailisrequiredtoimplementtheaction,theFLDSANTMshouldprovideguidanceandmonitortheactivitytoensurethatitisbeingproperlyimplemented.ArmyMedicalDepartmentTheArmyMedicalDepartment(AMEDD)supportsthiscommandprogrambyprovidingfieldpreventivemedicineservicesupportfrom5medicalfunctionalareas:preventivemedicineservices,veterinaryservices,preventivedentistry,combatandoperationalstresscontrol,andpreventivelaboratoryservices.TheAMEDDalsoconductsfieldpreventivemedicineresearchanddevelopmentforeachofthesefunctionalareastofurtherassistthecommandinthemitigationofDNBI.PREVENTIVEMEDICINESERVICESTheservicesprovidedbypreventivemedicinepersonnelarethemostdiverseandconstitutethebulkofappliedfieldpreventivemedicine(seeFM4-02.174).Theseservicesareprovidedbyofficersfrom8AreasofConcentration:PreventiveMedicineOfficer(60C),OccupationalMedicineOfficer(60D),PublicHealthNurse(66B),NuclearMedicalScienceOfficer(72A),Entomologist(72B),Audiologist(72C),EnvironmentalScienceOfficer(72D),andSanitaryEngineer(72E).Theseservicesarealsoprovidedby3enlistedMilitaryOccupationalSpecialties:PreventiveMedicineSpecialist(68S[formerly91S]),HealthPhysicsSpecialist(68SN4),andEar,Nose,andThroatTechnician(68WP2).Indeployedsituations,the68S,72D,and72Baretheprimarypersonnelwhointeractwithunitstoresolvefieldpreventivemedicineissues.Otherpreventivemedicinepersonnelarerepresentedonthestaffofvariousmedicalandnonmedicalunits.Preventivemedicinepersonnelsupportunitsinmedicalsurveillance,aswellasoccupationalandenvironmentalhealthsurveillance.ThissupportisaccomplishedthroughanalyzingDNBIdata,unitinspectionsforcompliancewithPMM,diseasesurveillance,areavectoranddiseasesuppression,healthriskcommunication,technicalconsultations,foodservicesanitationinspections,waterqualitymonitoring,pestmanagementservices,retrogradeoperationsinspections,hearingandvisionconservation,industrialhygienesurveys,fieldsanitationpractices,environmentalsamplingforshortandlong-termhealthriskexposures,communityhealthservices,andradiologicalsafety.Preventivemedicinepersonnelarelocatedthroughoutthebattlefield,andmustbedeployedduringearlyoperations.Some,suchasthePreventiveMedicineSectioninthebrigadecombatteamsmedicalcompany,areorganictounitsandprovidedirectsupport.Thissectioniscurrentlycomposedofa72Danda68S.OthersprovidestaffsupportandarefoundinPreventiveMedicineSectionsortheSurgeonCellsofcommandandcontrolorganizations.PreventivemedicinepersonnelarealsofoundinMilitaryPolicebattalions(Internment/Resettlement),SpecialForcesgroups,CivilAffairsbattalions/brigades,ArmoredCavalryregiments,Engineerunits,andsomeQuartermasterbattalions.MedicalDetachments(PreventiveMedicine)are13-memberunitsthatprovidedirectsupporttounitsthatdonothaveorganicpreventivemedicinepersonnel,andgeneralsupporttounitsthathaveorganicpreventivemedicinepersonnel.TheMedicalDetachmentsareattachedtomultifunctionalmedicalbattalions(MMB),operateonanareabasis,andhavethecapabilitytoprovideexpandedservices(especiallypestmanagementservices)tosupportedunits.VETERINARYSERVICESVeterinaryservicesincludethesurveillanceandtestingoffoodandwatersourcestoensurethesafetyandqualityoffood,ice,andbottledwater(seeFM4-02.185).Veterinarypersonnelestablishandprovidealistofapprovedfood,ice,andbottledwatersourcestothetheatercommanderandstafffordisseminationtosubordinateunits,andtheyprovidehealthservicesto *ThecomprehensivedocumentwillbeFM4-25.10:FieldSanitationTeamandPreventiveMedicineMeasures

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42ArmyMedicalDepartmentJournalmilitaryworkingdogs(MWDs).Veterinarypersonnelareseldomfoundatlowerechelonsonthebattlefield,butprimarilyinteractwithquartermasterunits,preventivemedicineunits,andunitsthathaveMWDs.VeterinaryunitswillalsobeassignedtotheMMB.PREVENTIVEDENTALSERVICESPreventivedentalservicesprimarilyinvolveindividualPMMsuchasregulardentalhygiene(brushing,flossing).FM4-02.19delineatesdoctrinefordentaloperations.6Dentistsalsoprovidepreventivesupportthroughannualdentalexamsandcleanings(includingpreventivemeasuressuchasfluoridetreatments),andwillprovideconsultationsonhowtoproperlybrushandflossteethandgums.Deployeddentalunitscanprovidein-theatertreatmentandpreventiveservices,normallywithahighreturntodutyrate.7Tofurtherassistwithpreventivedentalhealth,dentistslookforstrategiesthatmaintainanindividualsdentalhealththatareeffective,easytouse,andrequirenoadditionalactiononthepartoftheSoldier.Forexample,themilitarydentalcommunityhassucceededinhavingXylitolchewinggumaddedtothefieldrations,Meal,ReadytoEat(MREs).8Xylitolisanaturallyoccurringsugaralcoholthatkillsthebacteriathatcausescavities.AddingXylitoltoMREsassistsinthepreventionoftoothdecayandisano-effortbenefittothoseSoldierswhochewthisgum.COMBAT/OPERATIONALSTRESSCONTROLDeployedSoldiersaresubjectedtoamultitudeofissuesthatmaythatleadtosuicide,fratricide,asignificantreductioninworkperformance,orotherdisruptivebehavior.Theseissuesincludepreexistingconditionsthatarecorrectedbymedications;separationfromaspouse,asignificantother,orotherfamilymembers;fearoftheunknowncombatsituation;stressfromboredom,overwork,lackofsleep,seeingpeerskilledormaimed,andexperiencingotherwarconditions;andotherpersonalitydisorders.PreventingbehavioralissuesindeployedSoldiersistheroleofcombatandoperationalstresscontrolpersonnel(seeFM4-02.519)locatedinCombatandOperationalStressControlDetachments.ThesedetachmentsareattachedtoMMBsandprovidecontactteamstotheirsupportedunits.ThesecontactteamshavethecapabilitytointerviewSoldiers,evaluatethestressissueswithinacommand,provideguidanceonthepreventionofdisruptivebehaviortotheindividualforspecificissuesortothecommanderforunitissues,and,ifnecessary,providesomerehabilitatoryorreconstitutionservices.PREVENTIVELABORATORYSERVICESPreventivelaboratoryservicesarethoseservicesthatsupportthefieldpreventivemedicineeffortbytestingclinicalorenvironmentalsamplesforinfectiousagentsorhazardousmaterials.TheinformationfromtheseservicesareusedaspartoftheDNBIanalysisprocessandasdiagnosticsforunderstandingsurveillancedata.TheseservicesarelocatedwithintheAreaMedicalLaboratoryoroutsidetheaterinregionalorcontinentalUnitedStatessupportlaboratories.INDIVIDUALMEDICALREADINESSPersonnelarescreenedpriortoentryintomilitaryservicetoprevententryofrecruitsthathaveapreexistingmedicalconditionwhichwouldhindertheirperformance,ordisruptorburdenothermilitarypersonnel.Forthoseintheservice,periodicmedicalexamsortests(periodichealthassessments,deploymentlimitingconditions,dentalreadiness,immunizationstatus,readinesslaboratorystudies,individualmedicalequipment,hearingreadiness,andvisionreadiness)arerequired.TheseindividualmedicalreadinessdataareenteredintotheMedicalProtectionSystemviatheinternetandallowmedicalpersonneltoassesseachSoldier,andpreventortreataconditioninadvanceofdeployment.Thisinturnservestomaintainindividualhealth,unitintegrity,morale,andsavesdeploymentactivitiesforwarfighterissues.CommandersassistthisprocessbyensuringthattheirSoldierscompletetheseperiodicrequirements.DISEASEANDNONBATTLEINJURIES:PREVENTIVEMEDICINEMEASURESANDSOLDIERSEvenwiththebestpreventivemedicinepracticesinplace,someDNBIwilloccur.ThisDNBImayfluctuate.However,overtimeafairlystablerateofDNBIabaselinemaybeestablished.Ideally,thisbaselineshouldbethesameinbothnondeployedanddeployedsettings.IfthemeasuredDNBIexceedstheexpectedbaselineoranestablishedthreshold,preventivemedicinepersonnelinvestigatetheissue,lookforapotentialbreakinPMM,andimplementthemeanstomitigatetheDNBI.Withinthebodyofpreventivemedicineknowledge,muchisalready

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AprilJune200643knownonthepreventionofthemajorityofmilitarilyandmedicallyimportantDNBI.Unfortunately,DNBIsarebaseduponlawsofprobability,anditisnotalwaysclearthataspecificactionyieldsadirectconsequence.Hence,SoldierswhodonotpracticeeffectivePMMmaynothaveDNBI,whileSoldierswhopracticePMMmayhavesomeDNBI.ThismaycauseasenseofsecuritywhenPMMarenotfollowedandnoDNBIoccurs.Conversely,itmaycauseSoldierstomistrustrecommendedPMMandrelyonhome-remediesorrecommendationsfrompeerswhentheypracticePMMbutDNBIoccurs.BothsituationsmaycauseSoldierstostrayfromusingPMMastheyperceivePMMasbeingineffectiveortohavenoaddedvalue.However,unitleadersmustunderstandthatthePMMisnotatfault,butthatthereisabreaksomewhereintheimplementationofthePMMorthediseaseprocessthatispreventingorallowingtheDNBI.Preventivemedicinepersonnelaretrainedinlocatingthesebreaks,canexplainwhyDNBIsituationsexistordonotexist,andcanassistthecommandwithcorrectingtheissue.Insomecases,thePMMmayhaveasideeffectontheSoldier,andtoavoidthesideeffecttheSoldiermayavoidimplementingthePMM.Anexampleofthissituationwastheadministrationofchloroquineasachemoprophylaxisformalaria.Soldiersoftenhadgastrointestinalpainforseveraldaysaftertakingtheweeklydoseofchloroquine.Soldiersdidnotlikethissideeffectandwouldavoidtakingtheonce-a-weekmedication.UnitleaderscounteredthisbyhavingSoldierslineupinformationandobserveeachSoldierswallowthepill.Preventivemedicinemeasuresmustbesustainedonaroutinetoperiodicbasis,whichiscostlyintimeandresourcestotheSoldierandunit.ThemultitudeoftasksthatmustbecompleteddailyinafieldsituationtomaintainSoldierandunithealthcanappearenormous.Manyofthesetasksareexpectedingarrison(bathe,brushandfloss,washhandsafterusingthelatrineandbeforeeating,putoncleanclothes,changeyoursocksandunderweardaily,etc.),butinthefieldtheycanbecomeaninconvenienceand,withoutcommandemphasis,resourcing,andenforcement,Soldiersmayneglectthesebasichygienepractices.ForSoldierswhotakeprescribedmedicationstocounterbehavioralhealthissues,thelossofthesemedicationsorarrivingintheaterwithaninsufficientsupplycanbedisruptivetotheunit.TomitigatethisissueduringOperationIraqiFreedom,theArmyauthorizedunitmedicalpersonneltocarryandissuepsychotropicmedications.Soldiersmayalsodevelopaweretoughorawedontneedtowashourhandsortakeshowersonaregularbasisattitude.Soldiersmayalsoriskeatingordrinkingfromunapprovedsources.BothofthesecanleadtosignificantDNBI,andovercomingthemisaleadershipandtrainingissue.TheaterpoliciesdesignedtogainsupportofthelocalpopulationortoovercomeculturaldifferencesmayencourageSoldierstointeractwiththelocalpopulationandconsumetheirfoodandwaterinthetraditionalhostnationmanner.Sincethisfoodandwatermaynothavebeenhandled,prepared,stored,orservedusingmilitarystandards,theSoldiersmaybeexposedtoalocalbacterialorviralfaunatowhichtheyaresusceptible,resultinginincreasedDNBI.Commandersmustconsiderthehealth-relatedimplicationsofthesepoliciesastheyconducttheirriskassessments.CURRENTPREVENTIVEMEDICINEISSUESCurrentlythereareanumberofissuesthatmustbeaddressedtoimprovetheeffectivenessofpreventivemedicineservicesandprotectthehealthofwarfighters.Threesignificantissuesare:1.Thecurrentbrigadecombatteam(BCT)organizationalstructureplaces2initialentry-levelpersonnel(a72Danda68S)intheBCTmedicalcompanysPreventiveMedicineSection.TheseSoldiersarethewarfightersmostforward-deployedpreventivemedicineprofessionalsintheater,therefore,theyarethefirstlineoftechnicaldefenseintheBCTcommandersbattleagainstDNBI.Unfortunately,thesepersonnellackthetechnicalandtacticalexperiencetofullyaccomplishthisimportantmission.UnlikemanyoftheArmysareasofconcentration(AOC)/MilitaryOccupationalSpecialties(MOS)whichgrowtheirjuniorranksinfieldassignments,thepreventivemedicinepersonnelareexpectedtohavethelevelofknowledge,experience,andprofessionalbearingfoundinpersonnelwhohavebeeninthemilitaryforseveralyears.TheseprofessionalsarenotonlyexpectedtointeractwithSoldiersandtheFLDSANTM,buttheyalsointeractdirectlywithcommandersandseniorNCOs.WeproposecorrectingthissituationbyreplacingtheBCTsjunior68S(68S10)withamoreseniorspecialist(68S30).Thisactionwouldprovidetheknowledge,experience,andprofessionalbearingrequiredtosuccessfullyinteractwithSoldiersandunitleaders,resultinginincreasedmissionsuccess.The68S10sshouldfirstbegrowninotherassignmentswheretheywouldhavenoncommissionedofficersupervisionandmentorship.

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44ArmyMedicalDepartmentJournal2.Preventivemedicineunitsareequippedwithavarietyofhighlyspecialized,lowdensityequipmenttoconducttheirmission.Identifyingandresourcingtheseequipmentitemspresentsignificantchallenges:theyareexpensive,theyusuallyrequirespecializedandroutinemaintenance,theymayrequirespecializedoperationandmaintenancetraining,andtechnologicaladvancesmaymaketheseitemsobsolete3to5yearsafterprocurement.Also,althoughtheMedicalEquipmentSetcyclicreviewprocessrequiresCombatDeveloperstoreviewandupdatetheseitemsevery3years(asaminimum),duetoresourcingconstraintsunitsmaynotactuallyseetheseitemsforanother2to3yearsafterthereviewprocess.Asaninterimsolution,theUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)hasprovidedvaluableassistancetofieldpreventiveunitsbyprocuring,maintaining,providingtechnicaltraining,andtemporarilyissuingspecialized,low-densityequipmenttotheseunitsinsupportofmilitaryoperations.Examplesincludeairparticulatesamplersandcombinationphotoionizationdetectors/multigasanalyzersprovidedtopreventivemedicineunitsdeployedtotheBalkans,SouthwestAsia,andotherpartsoftheworldtoconducttheiroccupationalandenvironmentalhealthsurveillancemissions.Perhapstheprocurement,maintenance,training,andfieldingoflowdensity,hightechnologypreventivemedicinesupportequipmentshouldbefurtherexploredasacoreUSACHPPMmission,andtheorganizationshouldbeadequatelyresourcedtoprovidethisservice.3.Preventivemedicineunitsaretheoreticallydesigned(i.e.,staffedandequipped)toprovideavarietyofservicesdependingontheirpreventivemedicinesupportcapabilitylevel.Thetwo-personBCTPreventiveMedicineSectionprovidesdirectandbasic(LevelII)supporttoitsbrigade,whilethe13-personMedicalDetachment(PreventiveMedicine)providesgeneralareaandslightlymoreadvanced(LevelIII)supporttounits(toincludeBCTs)atthecorpslevel.TheAreaMedicalLaboratory(AML),ontheotherhand,isdesignedtoprovidetheater-wide,moretechnicallyadvanced(LevelIV)supporttotheseunits.However,otherthancontainingmorepersonnelandincreasedpestmanagementcapabilities,thePreventiveMedicineDetachmentdoesnotprovidesignificantlydifferentservicesthantheBCTPreventiveMedicineSection.AlthoughtheAMLcanprovideotherservices,theunitmaynotbeproperlyorganizedtodeployinamodular(andtimely)mannertomaximizeitsoperationalfootprintwhileminimizingitslogisticalfootprint.Therefore,theArmymayneedaLevelIII+orperhapsaLevelIVpreventivemedicineunittoprovidetheseadditionalservicesinamodularmanner.Thisunitmayperhapsbeassignedpersonnelfromeach72-seriesAOCandbeequippedwithmoreadvancedsurveillanceequipment,suchasdirect-readingtoxicmaterialanalyzers,toprovidemorerobustDNBIsurveillanceandcontrolservices.Infact,thisunitmaypossiblybeconfiguredmuchliketheUSNavysmodularForward-DeployedPreventiveMedicineUnit.FIELDPREVENTIVEMEDICINESTRATEGIESANDFUTUREPROSPECTSFuturefieldpreventivemedicinestrategiesarecomplex,andmultipleparametersmustbemettoprovideoptimalresults.Thesestrategiesmustmeetabalancebetweenwarfightermissionrequirements,politicalrequirements,andsupportrequirements,withtheultimatefocusonissuesthatwouldprovidethegreatestbenefittothewarfighterintermsofreducedDNBI.Thefollowingsectionsidentifysomeofthesefuturefieldpreventivemedicinestrategiesandprospects:1.Warfightersfocusonmissionaccomplishment;therefore,effortstoreducenonmissionrequirementsarewarranted.Futurepreventivemedicinestrategiesforthewarfightermustfocusonessentialcapabilitiesthatwillresultinwarfightermissionaccomplishmentwithminimalsupportrequirements.Ideally,thesesolutionsmustbeeasytouseorrequirelittleornoeffortfromtheSoldierorunitleaders,havehighSoldieracceptancelevels,behighlyeffective,havenooronlyminorsideeffects,begivenoraccomplishedinadvanceorafteradeployment,andrequirelittleplanning,training,orresourcestoimplement.2.Materielsolutionsmustalsofocusonprovidingincreasedcapabilities,whileatthesametimereducingequipmentweightandvolume.Effortsmustbetakentoconsolidate2ormorecapabilitiesintoasingle,portable,lightweight,andeasytooperateandmaintainequipmentitemwheneverpossible.AnexampleofthiseffortisRAESystems(3775NorthFirstStreet,SanJose,CA95134,408-952-8200)consolidationofastandalonephotoionizationdetector(capableofdetectingvolatileorganiccompoundsandotherionizablegasesandvapors)withastandalonemultigasanalyzer(capableofmeasuringexplosivegasesandvapors,oxygencontent,aswellascarbonmonoxide

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AprilJune200645andothertoxicgases)inthedesignoftheMulti-RAEPlusMultipleGasMonitor.3.Politicalrequirements,suchasthehealthsurveillancerequirementsmandatedbyPresidentialReviewDirective-5,10mustbemet.Theserequirementsfocusontheentirespectrumofmedicalsupportandrequirethewarfighterandmedicalpersonneltodocumentmedicaltreatmentandpreventivemeasures,aswellasexposurestoknownhazardsandenvironmentalconditions.Thesehazardsmustbeanticipated,identified,measured,assessed,andcorrelatedtolocationsandSoldiersexposed.Thesedatamustthenbelinkedtoindividualelectronichealthrecordsforfuturereviewandusebymedicalpersonnel.Thisisanenormoustask,andprocessestoefficientlycollect,analyze,andcorrelatethesedataareneeded.Rolesandresponsibilitiesmustbeestablishedtoensurethatthecorrectdataarecollectedandtoeliminateanyduplicationofeffort.Materielsolutionsarealsoneededtomoreeffectivelycollectandassesshealthhazardexposureinformation,andcreativeinformationmanagementsolutionsarerequiredfordataentry,correlation,archiving,andretrieval.4.Anumberofmedicalresearchprogramsarealreadyestablishedtoimprovefuturefieldpreventivemedicinecapabilities.ProgramssuchastheMilitaryInfectiousDiseaseResearchProgram(MIDRP)andtheMilitaryOperationalMedicineProgramfocusonpreventingandtreatingdisease,protectingwarfightersphysicalandmentalhealth,enhancingtheirperformance,andprovidingforcehealthstatus.Eachprogramwillestablishasetofparametersthatwillprovidethebestpossiblesolutionforthewarfighter.Forexample,vaccinesareamajorresearchfocusintheMIDRP.ThesemeetwarfighterrequirementsbypreventingDNBI,andtheycanusuallybeadministeredpriortodeploymenttoprotectthewarfighteragainstaparticulardisease.AdditionalvaccineparametersthatwillbenefittheboththewarfighterandtheArmymayincludevaccinesthatprovideprotectionsoonaftertheinitialvaccination;requireonlyonedosetoprovideahighlevelofprotectionwithnoboosters,oralongtimebetweenboosters;arehighlyeffective;havenooronlyminorsideeffects;aregiveninadvanceofadeployment;andrequirelittleplanningandlogisticalsupporttoimplement.Furthermore,thesevaccinesshouldbelowcost,havealongshelflife,areeasilymanufactured,easytoapply(oralorinhaled),easytostore,andhavelowdoseregimens.CONCLUSIONSArmyfieldpreventivemedicinemusthavecommandemphasisfromthetopdowntoincludeplanningconsiderations,trainingemphasis,andadequateresourcing.Mechanismsareinplacetosupportcurrentandfuturefieldpreventivemedicinethroughdoctrine,organization,andmaterielprocesses,witheachtobemodifiedasnewknowledgeandtechnologyimproveorchangetheimplementationofPMM.REFERENCES 1.ArmyRegulation40-5:PreventiveMedicine.Washington,DC:USDeptoftheArmy;22July2005.2.FieldManual4-25.12:UnitFieldSanitationTeam.Washington,DC:USDeptoftheArmy;25January2002.3.FieldManual21-10:FieldHygieneandSanitation.Washington,DC:USDeptoftheArmy;21June2000.4.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000.5.FieldManual4-02.18:VeterinaryServices,Tactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;30December2004.6.FieldManual4-02.19:DentalServiceSupportinaTheaterofOperations.Washington,DC:USDeptoftheArmy;1March2001.7.JonesTK.Armydentalservicesupportinatheaterofoperations.AMEDDJ.2006;JanMar:5-9.8.ScottAEJr.Xylitolchewinggum:arecommendedadditiontotheMREpackage.ArmyMedDeptJ.2006;JanMar:56-58.9.FieldManual4-02.51:CombatStressControlinaTheaterofOperations.Washington,DC:USDeptoftheArmy;29September1994.10.PresidentialReviewDirective-5(PRD-5)ANationalObligation-ImprovingtheHealthofOurMilitary,Veterans,andTheirFamiliesissuedinAugust1998.Availableat:http://fas.org/irp/offdocs/prd-5-report.htm.AUTHORS LTCSames,LTCDelk,andMAJLyonsareallmembersofForceProtectionBranch,DirectorateofCombatandDoctrineDevelopment,USArmyMedicalDepartmentCenter&School,FortSamHouston,Texas.

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46ArmyMedicalDepartmentJournalItistheArmysresponsibilitytoensurethatSoldiersareprotectedduringdeployments(bothdomesticandoverseas)againstanyhazardsorthreatagents,andtodocumentpotentialoractualexposurestotheseharmfulthreatagents.ThedocumentationdatabasewillallowhealthcareproviderstobettertreatandmanageSoldiersifanillnessoccursafterdeployment,orevenafterseparationfromthemilitary.TherecordispermanentandalwaysavailabletotheSoldier.TheDeploymentOccupationalandEnvironmentalHealthRiskManagement(DOEHRM)ProgramwillgreatlyassistindealingwithpostconflictillnesseswhichhaveoccurredfollowingUSmajormilitaryengagements.ThisarticlepresentsabriefhistoryoftheDOEHRMprogramandexistingorplannedinitiativesforprogramenhancement.Inthe1991GulfWar,thenumberofcoalitioncasualtieswassignificantlylowfromanhistoricalperspective.However,neitherservicepersonnelnortheAmericanpublicwerepreparedtodealwithsignificanthealthissuesamongreturningveterans.Ofparticularimpactwerethoseveteranswhosesymptomsandconditionswerenoteasilydiagnosedortreated.Tocomplicatematters,themilitaryservicessoonbecameawareof3seriousshortcomings;1.theinabilitytotrackspecificdailylocationsfordeployedpersonnelandunits,makingitextremelydifficulttocrossreferencelocationswithpotentiallydangerousoccupationalandenvironmentalhealthexposures,2.thehealthriskcommunicationsprocesswasdeficient,and3.thelackofformalpre-andpostdeploymentscreeningprocesses(Note:screeningshavesincebeenimplemented).DeploymentOccupationalandEnvironmentalHealthRiskManagementCOLRobertR.Eng,MS,USACOL(Ret)CurtisW.Pearson,MSC,USAF

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AprilJune200647Severalofthepostwarhealthconcernscenteredonveteransillnesses,mortality,hospitalizations,andreproductiveoutcomeissues.Forexample,whyweresomeveteransillwithunexplainablesymptomsandwereuntreatableaswell,leavingpractitionersunabletoexplaindiagnosis,prognosisandlongtermrecoveryissuestothem?Whatweretheacute,chronic,ordelayedhealthrelationshipsamongpesticideexposures,vaccinationsandantidotes,air/soil/waterpollutants,chemicalandbiologicalwarfareagents,stress,depleteduranium,andothers?Whatexactlyhappenedwithina50kmradiusofKhamisiyah,Iraqwhenitwasdestroyedbycoalitionforces?Whataboutpotentialexposuresatotherlocations?Wereveteranswhodeployedmorelikelytobecomeilland/orhospitalizedversusthoseveteranswhohadnotdeployed?AndwhataboutbirthdefectsamongchildrenborntoGulfWarveteransdidthewarexperienceshaveanythingtodowiththat?Toaddresstheshortcomingsduringsubsequentdeployments,thePresidentialAdvisoryCommittee ArmyDOEHRMpolicyobjectives:1.ProtectArmypersonnel,includingDeptoftheArmyciviliansandArmycontractors,frompotentialandactualexposuresonthebattlefield.Theseexposuresincludechemical,biological,radiological,andnuclear(CBRN)warfareagents;endemiccommunicablediseases;food,water,andvectorbornediseases;ionizingandnonionizingradiation;combatandoperationalstress;heat,cold,andaltitudeextremes;environmentalandoccupationalhazards;toxicindustrialmaterialsandotherphysicalagents.2.ReduceoccupationalandenvironmentalhazardpotentialandactualexposuresduringArmyoperationstoaslowaspracticabletominimizeacute,chronic,anddelayedhealtheffectswithinthecontextofmissionparametersandArmyriskmanagement(RM)principles.3.Makeinformedriskdecisionsregardingoccupationalandenvironmentalhealth(OEH)threatsduringArmyoperations,usingtheRMprocesstomanagesuchthreatsandminimizetotalrisktoArmypersonnel.4.Ensurethatcommandersareawareofandconsideracute,chronic,anddelayedhealthrisksassociatedwithoccupationalandenvironmentalpotentialandactualexposuresduringallphasesofArmyoperationsandactivities.5.Complywithfederal,state,localorhostnationstatutes,regulations,directives,andguidancegoverningOEHexceptforuniquelymilitaryequipment,systems,andoperationswhileingarrisonorduringtrainingexercises.6.Duringdeployments,complywithUS,Army-unique,orhostnationOEHstandards,whicheveraremorerestrictive.7.ImplementhealthsurveillanceandreadinessprogramsduringArmyoperations.8.Collect,document,evaluate,report,andarchiveOEHsamplingdatafromArmyoperations,integratingallrelevantOEHdatawithpotentialandactualexposuresandexposurescenariostoindividualArmypersonnel,intheirlongitudinalhealthrecords.9.EnsurenecessaryhealthcareinterventionandfollowupforpotentiallyexposedArmypersonnel.10.DeployinsuchawaythatDOEHRMsupportsmodularandinteroperablejointforcescapabilitiesprovidedbytheservices.11.CommunicateOEHrisksfrommilitaryoperationstoallArmypersonnelandshareOEHriskmanagementlessonslearnedduringunitrotations.12.ProvidecommanderswiththecapabilitiesandtoolsforconductingRMassessmentsandcommunicatingrisks.13.Provideaccesstoallneededintelligencesources,deployablecomputersystemswithenvironmentalexposuredata,unitlocations,andmovementinformation.

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48ArmyMedicalDepartmentJournal(PAC)onGulfWarVeteransIllnesseswasestablished.InitsfinalreportissuedonDec31,1996,thePACrecommendedthattheNationalScienceandTechnologyCouncil(NSTC)developaninteragencyplantoaddresshealthpreparednessfor,andreadjustmentof,veteransandtheirfamiliesafterfutureconflictsandrelatedmilitarymissions.TheNSTCrecommendationresultedinPresidentialReviewDirective-5(PRD-5),ANationalObligation-ImprovingtheHealthofOurMilitary,Veterans,andTheirFamiliesissuedinAugust1998.*TheDeputyAssistantSecretaryoftheArmy(Environment,SafetyandOccupationalHealth)(DASA[ESOH])directedimplementationoftherecommendationscontainedinPRD-5inthememorandumForceHealthProtection:OccupationalandEnvironmentalHealthThreatsdated27June2001.WithencouragementandsupportfromtheArmySurgeonGeneral,LTGJamesPeake,theArmyDeputyChiefofStaff(DCS),G-3/5/7tooktheleadresponsibilitiesforimplementation.TheprogramwasrenamedDeploymentOccupationalandEnvironmentalHealthRiskManagementtobetterdescribetheintentoftheDASA(ESOH)memo.Aspartoftheprogram,agoverningArmyregulationinthe11seriesisinfinalstaffingasthesourcedocumentforDOEHRM.The11series(ArmyPrograms)ofregulationswaschosenastheappropriatelocationfortheDOEHRMregulationsinceitrepresentsmuchmorethanamedicalissue.DOEHRMisanArmyissuetobeexecutedbycommandersandtheArmyleadership.InadditiontotheimpendingArmyregulation,animplementationplanforDOEHRMhasbeenauthored,directingnumerousorganizationswithintheArmytoincorporateDOEHRMintotheirrespectiveareasofresponsibility.WithfinalizationoftheDOEHRMregulationandpublicationoftheimplementationplan,majorcommands(MACOMs)andSpecialStaffwillbetaskedtoauthortheirownimplementationplansandidentifyrequirementsfortheprogram.TheDCS,G-3/5/7willthenassembleandvalidateallMACOMrequirementsasidentifiedintheMACOMandSpecialStaffimplementationplans,andstaffDOEHRMthroughtheProgramObjectiveMemorandumprocessforimplementationthroughouttheArmy.WiththeguidanceasprovidedbytheArmyregulationandthespecificinstructionsoftheDOEHRMimplementationplan,MACOMsandArmystaffofficeswillberesponsibleforDOEHRMintegrationintotheirrespectiveareasofresponsibility.Forexample,thefollowingarerepresentativeleadresponsibilitiesofseveralmajorArmyorganizations:1.TheDCS,G-3/5/7willensureallrelevantArmypublicationsaremodifiedtoincludeDOEHRM;reviewmodifiedtablesoforganizationandequipmenttoensureDOEHRMequipmentrequirementsareproperlyincluded;integratetheDOEHRMimplementationplanwithcurrentandfutureCBRNandhighexplosivesurveillanceandbioanalysissystems;identify,trackandreviewDOEHRMissues,resolutionandassessments.2.TheTrainingandDoctrineCommandwilldevelopandpublishDOEHRMdoctrineinaccordancewithdoctrine,organization,training,materiel,leadership,personnel,andfacility(DOTMLPF)domains;developconsistentoperationalguidancethatallowsappropriatepersonneltoassistcommandersinmanagingrisksfromdeploymentoccupationalandenvironmentalhealthhazardsandincorporatingsameintotheArmyDOTMLPFprocess;asDOEHRMrequirementsareidentified,examineforcestructuretoensuresaid*Availableat:http://fas.org/irp/offdocs/prd-5-report.htm.

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AprilJune200649requirementsaredefinedandaddressedbyappropriateorganizations;reviewcurrenttrainingpracticestoensureappropriateriskisbeingcommunicatedtothosehavingDOEHRMresponsibilities;developexportableleaderandSoldiertrainingpacketsonsustainmentDOEHRMtrainingforallcomponentsafterdoctrineisapproved;developunit/organizationtrainingprograms.3.TheDCS,G1willreviewandidentifymodificationstoorexpansionofChapter7(MedicalandDental)oftheDepartmentoftheArmyPersonnelPolicyGuidanceforContingencyOperationsinSupportofGWOT*(globalwaronterror)toaccommodateDOEHRM;reviewand/ordeveloppersonnelpoliciestosupportintegrationanddirectaccessofdailypersonnelandunitlocationcross-referenceddatainDOEHRMinformationmanagement/informationtechnology(IM/IT)systemsincoordinationandlinkagewithotherIM/ITsystems.4.TheMedicalCommandwilldevelop,improve,anddisseminatecriteriaandguidancetoinclude,butnotbelimitedto,chemical,biological,radiological,nuclear,highexplosive,physical,entomological,combatandoperationalstresshealthrisks,endemicdiseases,andpreventivemeasuresthroughouttherangeofexposurelevelsforacute,chronic,anddelayedhealtheffects;examinemedicaltechnologytransitionprojectsandprocessesforpotentialDOEHRMapplicabilityandpriority;conductreviewsofexistingmedicalresearchanddevelopmentprogramstodetermineDOEHRMapplicabilityandopportunitiesforintegration.5.TheCombatReadinessCenter(CRC)willintegratetheDOEHRMimplementationplanwiththeCRCstrategicplanandintoRMdoctrine.6.ForcesCommandwillincorporateproceduresintheDOEHRMimplementationplanintoallmissiontrainingplansanddeploymenttrainingexercisesforbothlineandmedicalunits.OtherMACOMsandstaffofficeshaveadditionalresponsibilitiesoutlinedintheimplementationplan.TheSurgeonGeneralisconfidentthat,undertheleadershipoftheDeputyChiefofStaff,G-3/5/7,theDOEHRMprogramwillenablecommanderstobettermanagetheirwar-fightingresponsibilitiesand,atthesametimeminimizeharmfuloccupationalandenvironmentalhealththreatexposurestotheSoldier,DeptoftheArmycivilian,andArmycontractor.AUTHORS COLEngistheDirector,ProponencyOfficeforPreventiveMedicine-SanAntonio(POPM-SA)atHeadquarters,USArmyMedicalCommand,FortSamHouston,Texas.COL(Ret)PearsonisemployedbytheBattelleMemorialInstituteastheSeniorTechnicalConsultanttoPOPM-SAatHeadquarters,USArmyMedicalCommand,FortSamHouston,Texas

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50ArmyMedicalDepartmentJournalIn1996,theUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)formedtheDeploymentEnvironmentalSurveillanceProgram(DESP).ThisprogramwasformedtofulfilltheUSACHPPMroleastheDepartmentofDefense(DoD)executiveagentfordeploymentoccupationalandenvironmentalhealth(OEH)surveillancemeasures,databases,dataanalysis,andsupportitems.Theprogramgreatlyassistedinimplementationofpreventivemedicinelessonslearnedfollowingthe1991GulfWarbyfocusingdeploymentOEHsurveillancemeasuresandarchivedata,reports,andassessments.AnoverviewofUSACHPPMdeploymentsupportofmajorUSmilitarydeploymentssince1991ispresentedinFigure1.AtthebehestoftheArmySurgeonGeneral,theDirectorateofHealthRiskManagement(DHRM)wasformedin2001toenhancethereadinessoftheUSArmy.TheDESPandtwoexistingUSACHPPMprogramswererealignedundertheDHRM.TheDirectorateisstaffedbyprofessionalscientists,engineers,andtechnicianswhoprovideawidevarietyofservicessupportinghealthriskmanagement.TheseservicesenabletheArmyandDoDleadershiptoincorporateinformedriskmanagementdecisionsintoallArmyandDoDactivities.TheDESPworkloadexpandedexponentiallywiththeincreasedoperationaltempooftheworldwidedeploymentofforcesforOperationsEnduringFreedomandIraqiFreedom,andtheglobalwaronterrorism.ThisexpansionincludedUSACHPPMsdesignationastheDoDrepositoryforarchivesofdeploymentOEHsurveillancedata.Inaddition,theincreasedworkloadincludeddeploymentOEHsurveillancetrainingandcoordinationwiththeArmy,Navy,AirForce,andMarineCorps,andcollaborationwithCoalitionForces.USACHPPMrestructuredtheDESPin2004toenhancethemissionfocusonwarfightersreadiness,supporttheUSACHPPMstrategicvision,andrespondtotheincreasedworkloadofworldwidedeployments.Therestructuringadded2newprogramsundertheDirectorateofHealthRiskManagement,appropriatelynamedtheGlobalThreatAssessmentProgramandtheDeploymentDataArchiveandPolicyIntegrationProgram.TheDESPwasmaintainedforcurrentdeploymentOEHsurveillancesupportmeasures.The3programsprovidecomprehensivedeploymentOEHsurveillancemeasures(Figure2)andpreventivemedicinesupportasoutlinedinDoDandJointChiefsofStaff(JCS)surveillancerequirements.The3restructuredDHRMprogramsensuretimelycomprehensivedeploymentOEHsurveillancesupporttotheirbroadcustomerbase,whichincludesdeployedpreventivemedicineunitsoftheArmy,Navy,andAirForce;CombatantCommands(COCOM);ComponentCommands;JointTaskForces(JTF);DoD;DepartmentsoftheArmy,Navy,andAirForce;DepartmentofVeteranAffairs;JointStaff(J4-HealthServiceSupportDivision);OfficeoftheAssistantSecretaryofDefenseforHealthAffairs;OfficeoftheDeputyUnderSecretaryofDefense,InstallationsandEnvironment;andtheArmySurgeonGeneral.DeploymentOccupationalandEnvironmentalHealthSurveillance:EnhancingtheWarfightersForceHealthProtectionandReadinessJeffreyS.KirkpatrickLTCChristineMoser,MS,USABradE.Hutchens,PE NOTE:TheremainderofthisarticleisorganizedintothreemajorsectionsdetailingtheGlobalThreatAssessmentProgram,theDeploymentEnvironmentalSurveillanceProgram,andtheDeploymentDataArchiveandPolicyIntegrationProgramrespectively.Thereferencesandauthorinformationforallsectionsareconsolidatedattheendofthearticle.

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AprilJune200651OVERVIEWTheGlobalThreatAssessmentProgram(GTAP)wasprecededbytheGlobalThreatAssessmentTeam,whichfunctionedfromSeptember2003throughSeptember2004.Priortothat(1996to2002),predeploymentOEHfunctionswereperformedexclusivelyundertheDESP.TheGTAPwascreatedtoidentifyandassessdeploymentOEHhazardsandthreatsforworldwideCOCOM,ComponentCommand,JointTaskForce,andthemilitaryservicesprioritydeploymentareas,bothexistingandplanned.TheseassessmentsareusedbytheOEHsurveillanceactivitiesthatsupporttheintelligencepreparationoftheenvironmentduringoperationalplanning.TheGTAPworkswithUSintelligenceactivities,includingtheDefenseIntelligenceAgencysArmedForcesMedicalIntelligenceCenter,theNationalGeospatial-IntelligenceAgency,theArmysNationalGroundIntelligenceCenter,andotherdomesticandoverseasresourcestoobtainpertinentintelligencedataandotherproductstosupporttheUSACHPPMmission. 1991199319951997 199920012003 2005 1992199419961998 200020022004 OperationDesertStorm (KuwaitOilWellFires) OperationVigilantWarrior (Kuwait) OperationJointEndeavor(Bosnia) OperationAlliedForce/JointGuardian (Kosovo) OperationDesert Thunder(Kuwait)OperationEnduringFreedomOperationIraqiFreedom JTFKatrina Figure1.OverviewofmajorUSmilitarydeploymentssince1991forwhichUSACHPPMprovided deployment occupationalandenvironmentalhealthsurveillancemeasures.GLOBALTHREATASSESSMENTPROGRAMJeffreyS.Kirkpatrick

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52ArmyMedicalDepartmentJournalTheGTAPcoordinateswiththeatercustomerstoensurethatallpredeployment(phaseI)OEHsurveillanceproductsareexpeditiouslyrequested,produced,anddisseminated.GTAPproductionprioritiesarebasedonthefollowingongoingDoDcampaignsandmissions:GlobalWaronTerrorismOperationIraqiFreedomOperationEnduringFreedomTheatertransformationPeacekeeping/humanitarianmissionsInaddition,anyproductsthatarerequiredtosupportaUSACHPPM-basedmission(eg,specialmedicalaugmentationresponseteampreventivemedicine)areintegratedwithandmanagedagainstcurrentproductionpriorities.Finally,allproductsarecoordinatedwithandvalidatedbytherequestingagency,activity,orunit,includingCOCOM,ComponentCommand,and/orthemilitaryservice.TheGTAPproducescomprehensive,all-source(ie,informationderivedfromallintelligencedisciplines,includinghuman,signal,imagery,andopensources)technicalassessmentsofdeploymenthazardsandthreatstodeployedanddeployingUSarmedforces.Normallyclassified,thedeploymenthazardsandthreatsinanassessmentinclude:industrialchemicalshistoricalcontaminationradiationinfectiousdiseaseentomologicalrisksweaponsofmassdestruction(chemical,biological,radiological,nuclear)unexplodedordnancespecificthreatsidentifiedbyrequirements(eg,oilinfrastructuresabotage)Bothspecifichazardandthreatoperationalriskmanagement(ORM)estimatesandanintegrateddeploymentbasedORMestimatearegeneratedusingmethodsandproceduresoutlinedinUSACHPPMTechnicalGuides230and248.1,2TheGTAPdevelopspertinentinputandsubsections(tabs)forthemedicalservicesannex(AnnexQ)ofCOCOMandComponentCommandoperationsplans.Arecentexample:tabsdealingwithoilsabotagedevelopedfortheUSCENTCOMSurgeoninsupportofoperationalplanningforOperationIraqiFreedom.Inadditiontoitsforecastingandplanningresponsibilities,theGTAPdevelopsandcoordinatesdeploymentOEHsurveillancesamplesummaryassessmentsforcurrentmilitaryoperations.Theassessmentshelpupdatetheoperationalriskmanagementestimatesbasedoncollectedandanalyzeddeploymentsamplesandassistinrefining AssessandSelectoperatingsitesandbasecampsEstablishOEHRiskLevelsOPLANPreparationEnsureriskcontrolmeasuresareworkingDocumentexposurestoacuteandchronichealthrisksValidateOEHRisksDocumentalldeploymentrelatedexposuresandhealthrisksArchiveandMaintainforfutureassessmentsEpidemiologyWork>30daysinitialdaystoweeksPHASEIIMOBILIZATIONPHASEIVPOST-DEPLOYMENTPHASEIIICONFLICT OEHSEquipmentandMediaResupplyAnalyticalSupportOEHSOperationalRiskAssessmentsIncidentResponseDataArchivingOEHSEquipmentRedeploymentConsolidatedDataReportingReassessOEHThreatDataArchivingPHASEIPRE-DEPLOYMENTIdentify,assessandcontrolexposuresOEHrisksObtainingOEHSInfo&IntelligenceOperationsPlan(OPLAN)Input G o a l s EnvironmentalHealthSiteAssessment EnvironmentalBaselineSurvey(EBS) RoutineOEHS EBSCampClosure OEHSExposureSummary Pre-andDuring-DeploymentOEHSAssessments OEH/IntelligencePreparationofEnvironment(IPE)ThreatAssessmentOEHSEquipment/Training A c t i o n s GTAPGTAP DDAPIDDAPI DESPDESP Identify,Assess,Control,CommunicateDOEHSRisks Figure2.TasksandgoalsofthedeploymentOEHsurveillanceprocessbyphase,includingthetimelineofinvolvementoftheGlobalThreatAssessmentProgram,theDeploymentEnvironmentalSurveillanceProgram,andtheDeploymentDataArchiveandPolicyIntegrationProgram.

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AprilJune200653informationondeploymenthazardsandthreatsforcurrentandfutureuse.TheGTAPalsomaintainsandpopulatestheUSACHPPMclassifiedwebsiteandinteractivemapserverontheSIPRNET(secureinternetprotocolrouternetwork).ACTIVITIESAsillustratedinFigure1,from1996to2002theDESPproducedanddisseminatednumerouspredeploymentOEHproductsinsupportoftheplanningandexecutionofmilitaryoperationsandexercisesinEuropeincludingBosniaandKosovoandsouthwest,central,andsoutheastAsia.OEHproductssupportedOperationEnduringFreedom/JointForge(Bosnia);OperationAlliedForce/JointGuardian(Kosovo);OperationSouthernWatch(Kuwait,SaudiArabia);andOperationEnduringFreedom(Afghanistan,Pakistan,Uzbekistan,Kyrgyzstan,Philippines).Sinceearly2003,theGTAPhasprovidedpredeploymentsupporttoCOCOM,ComponentCommands,JointTaskForces,variousDoDsecretariats,anddeployingarmedforcesinaccordancewithDoDdirectivesandJCSguidelines.ThesupporteffortsprovidedthedeployingforceswithpertinentdeploymentOEHsurveillanceassessmentsandinformationonknownandpotentialhealththreats,risks,andenhancedsamplingrequirementsformainoperatingbases,forwardoperatingsites,cooperativesecuritylocations,andotherknownandplannedlocationsofmilitaryinterest.Commandersandstaffsections(surgeon,intelligence,engineer,planners,operations,preventivemedicine)usetheassessmentsandinformationtoplanandimplementcomprehensiveforcehealthprotectionfordeployingforces.Whenneeded,theGTAPensuresthatallappropriatesecurityclassificationmeasuresareidentifiedandcoordinatedwithallconcernedorganizations.TheGTAPsupportsothergovernmentandalliedorganizationswithpredeploymentOEHinformation.TheseorganizationsincludetheOfficeoftheDeputyUnderSecretaryofDefense(Installations&Environment);theDepartmentofState;andcoalitionpartners(ie,Australia,Canada,andtheUnitedKingdom).TheGTAPcontinuestosupporttheworldwidemilitarydeploymentoperationsfortheglobalwaronterrorism.Currently,theUSSpecialOperationsCommandistheleadCOCOMintheprosecutionofthismajor,longtermcommitment.The5majorgeographiccombatantcommandsareidentifyingknownandpotentiallocationsofinterestintheirrespectiveareasofresponsibility.Thisincludesplanningforoverseasbases,personnel,infrastructure,andequipmenttobetterpositionUSforcestostrengthenalliedandpartnernationrelationshipstodefeatterrorismandmeetfuturechallenges.Concurrentwithongoingworldwidedeploymentplanningandoperations,DoDisactivelyengagedinglobalpostureefforts,whichfocusontherestructuringoftheUSglobaldefenseposture.GTAPsupportstheDoDIntegratedGlobalPresenceandBasingStrategywhichoutlinesthelongterm,comprehensive,integratedoverseasstrategy.Inall,thelocationswillbeidentifiedasacooperativesecuritylocation(ahost-nationfacilitywithlittleornopermanentUSpresence),aforwardoperatingsite(anexpandablehost-nationsitewithlimitedUSmilitarysupportpresenceandpossiblyprepositionedequipment),oramainoperatingbase(anenduringstrategicbaseestablishedinfriendlyterritorywithpermanentlystationedcombatforces,commandandcontrolstructures,andfamilysupportfacilities).TheGTAPwillproducephaseIassessmentsordeploymentOEHsurveillancesummaryassessmentsforidentifiedsitesastasked.Domestically,theUSNorthernCommand(USNORTHCOM),establishedin2002,isheavilyinvolvedwithhomelanddefenseefforts,providingmilitaryassistancetocivilauthorities(includingconsequencemanagementoperations),andmaintainingtheatersecuritycooperationwithintheirareaofresponsibility(mainlyCanadaandMexico).TheHurricaneKatrinaresponse(2005)byDoDsJointTaskForceKatrina(underUSNORTHCOM)highlightedtheneedfordevelopment,expansion,andintegrationofmorecomprehensiveforce(andpublic)healthprotectionitemsinplanningactivities.Finally,asdiscussedindetailinanaccompanyingarticle(page46),theDepartmentoftheArmysDeploymentOccupationalandEnvironmentalHealthRiskManagement(DOEHRM)programpolicyhas13majorelementsthatenablecommanderstobettermanagetheirresponsibilitiestominimizebothknownandpotentialdeploymentOEHexposurestoSoldiers,

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54ArmyMedicalDepartmentJournalDepartmentoftheArmy(DA)civilians,andArmycontractors.ThefirstmajorelementidentifiedinthispolicyistheprotectionofArmypersonnel,includingDAciviliansandArmycontractors,frompotentialandactualexposuresonthebattlefield.Inaddition,thepolicyalsodiscussestheuseofoperationalriskmanagementpracticesandensuringthatcommandersareawareofandconsideracute,chronic,anddelayedhealthrisksassociatedwithoccupationalandenvironmentalpotentialandactualexposuresduringallphasesofArmyoperationsandactivities.ThecurrenteffortsoftheGTAPareinlinewiththeoverallintentofthispolicy.However,notallidentifiedelementsareincompletecompliance,andadditionalresourcingeffortsarenecessarytorealizethecomprehensiveintentoftheDOEHRMpolicy.Acknowledgement:MumtazAli,LouisG.Boomsma,MariRobinette-Deasel,SuhaleM.Fathimulla, FarhanaLotlikar,andSherriC.Whitemancontributedinthepreparationofthissection. DEPLOYMENTENVIRONMENTALSURVEILLANCEPROGRAMLTCChristineMoser,MC,USATheDeploymentEnvironmentalSurveillanceProgram(DESP)providescoordinationoftechnicalconsultativereach-backassistanceconcerningdeploymentoccupationalandenvironmentalhealth(OEH)surveillanceissues,operationalriskmanagementestimateassessments,andcoordinationofsamplecollectionequipment.TheseeffortssupplycommandersanddecisionmakerswithpertinentdeploymentOEHsurveillanceinformationneededtodetect,assess,andcounterthreatsandhazardsaspartoftheComprehensiveMilitaryMedicalSurveillanceProgramrequiredbytheDoD.3TheexistingDESPmissionsupportstheArmyDeploymentOccupationalandEnvironmentalHealthRiskManagement(DOEHRM)program(seeaccompanyingarticle,page46)bychampioningthecollection,documentation,evaluation,andreportingofOEHsamplingdatainthestandardoperationalriskmanagement(ORM)principleformat.TheDESPinformscommandersanddecisionmakers,throughtheirrespectivepreventivemedicinepersonnel,ofthehealthrisksassociatedwithoccupationalandenvironmentalpotentialandactualexposuresduringallphasesofArmyoperationsandactivities.ArmedwiththisOEHoperationalriskestimate,commanderscanmakeinformeddecisionsaboutproperlymitigatingtheOEHriskswhilebalancingtheoperationalrequirementsofthemission.TheDESPprovidescoordinationoftechnicalconsultativereach-backassistanceconcerningdeploymentOEHissues,samplecollectionequipment,media,andshippingcoordination.EachdiscretesamplingeventisinterpretedandsynthesizedintoadeploymentOEHriskcharacterizationreportbyutilizingtheoperationalriskmanagementmodel.Thereportassistscommandersandpreventivemedicineprofessionalswithidentification,reduction,andpreventionofpotentialOEHhazards.DESPpersonnelprovidetrainingassistancewithregardtoOEH-uniqueequipmentandtheORMprocess.TheDESPisthecentralpointofcontacttocoordinateandanswerdeploymentOEHquestionsfrompersonnelinbothpredeploymentanddeployedphases.DESPpersonnelcollaboratewiththetechnicalexpertswithinUSACHPPMorotherorganizationsasnecessarytolinkcustomerswiththecorrectanswers,orthetechnicalexpertsbestsuitedtoprovidetheanswers.Currently,theArmypreventivemedicineassetsassignedtobrigadecombatteams,divisionheadquarters,specialforcesgroups,andpreventivemedicinedetachmentsdonotpossessthetypeofequipmentrequiredtoperformextensiveambientair,water,orsoilsamplingaspartoftheirorganicmilitaryauthorizedequipment.TheUSCentralCommand(USCENTCOM)developedanoperatingconceptfortheaterforcehealthprotectionofjointandinteroperablepreventivemedicinesupport.Underthatconcept,theAirForceExpeditionaryMedicalSupportunitsandPreventiveMedicineTeams,theNavyForwardDeployedPreventiveMedicineUnits,andMarineExpeditionaryForcesperformtheOEH

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AprilJune200655surveillancemission.Table1presentsthevarietyofdeploymentsamplingequipment,media,andadministrativeaccessoriessuppliedtothetri-SservicepreventivemedicineassetsbyDESP.Additionally,theDESPsuppliessamplingmediaandsuppliesincludingpreservatives,gloves,coolers,smalltools,barometers,thermometers,etc.Althoughmanypreventivemedicineunitspossessglobalpositioningsystems(GPS),DESPprovidesGPSequipmentthatisdedicatedtotrackingthelocationofair,water,andsoilsamplesforfuturegeospatialmapping.DESPpersonnelcanalsoassistwithdevelopingasite-specificsamplingplan.AsdetailedinTable2,betweenMay1991andApril2006,theDESPprovidedworldwideequipmentandlabanalysisinterpretationofapproximately17,000deploymentsamples.ItshouldbenotedthatalthoughtheUSCENTCOMtheaterofoperationssamplenumbersarethemselvesrobust,DESPOEHsurveillanceresponsibilitiesextendtotheEuropeanCommand,thePacificCommand,theSouthernCommand,USNORTHCOM,andtheArmySpecialForcesCommand.Forexample,between1999and2006,atotalof120air,water,andsoilsampleswerecollectedfromtheDominicanRepublic,ElSalvador,Honduras,Nicaragua,Dominica,Guatemala,Guyana,Haiti,andPanama.ThedeploymentOEHriskassessmentreportsforthesampleslistedinTable2arecreatedusingtheoperationalriskmanagementdoctrineincludedinArmyFieldManual100-144andtherelativelyconservative(protective)assumptionsandmethodscontainedintheUSACHPPMTechnicalGuide2301tofacilitatedecision-makingthatcanminimizethelikelihoodofsignificantrisks.TheDESPfacilitatesintegrationofmedicalthreatsintomissionriskassessmentsasdescribedintheUSACHPPMTechnicalGuide248.2DESPsuppliessandflyandmosquitosurveillanceequipmentandmediatothetri-ServicepreventivemedicineresourcesinvolvedinOperationsIraqiFreedomandEnduringFreedom.MosquitoandsandflysurveillanceisperformedbyUSACHPPMlaboratoriestoanalyzevectorsthatsignificantlyimpactreadinessbytransmittingdisease(malariaandlieshmaniasis,respectively),analyzespecimensforinfectivityoftheorganism,andimpacttheoutcomeoftheoperationalchemoprophylaxispolicy.Tri-Servicepreventivemedicinepersonneltypicallyperformtheair,water,soil,andvectorsurveillancefunctionsindeployedsettings.However,theUSACHPPMcandeployaSpecialMedicalAugmentationResponseTeamPreventiveMedicine(SMARTPM)uponrequestandvalidationbythecorrespondingcomponentcommandsurgeonsofficeforanidentifieddeploymentOEHsurveillancemissionrequiringsubjectmatterexpertise,intensetimecommitment,anddedicatedfocus.Thescopeoftheteamsexpertiseistailoredtomeetthemissionrequirements.TheDESPcivilianOEHsurveillancesubjectTable1.Equipment,Media,andAccessoriesSuppliedbytheDeploymentEnvironmentalSurveillanceProgramEquipmentIntendedParameters DeploymentsoilkitsMetals,pesticides,polychlorinatedbiphenyls,herbicides,semi-volatileorganiccompounds(SVOCs)DeploymentwaterkitsMetals,volatileorganiccompounds(VOCs),pesticides,inorganics,radionuclidesAirmetricsMini-VolParticulateSamplerParticulatematterwithadiameterlessthan50m,10m,and2.5mandheavymetalsSKCpumpsVOCsSUMMACanistersVOCsPS-1highvolumeambientairsamplerDioxins,furans,SVOCs,pesticides,Polycylicaromatichydrocarbons AirsamplinginKuwait

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56ArmyMedicalDepartmentJournalTable2.DeploymentOccupationalandEnvironmentalHealthSurveillanceSamplesfortheperiodMay1991ThroughApril2006OperationorExerciseTimePeriodDeploymentSamplesGeographicArea(TypeSamples) DesertStorm19915,000KuwaitandSaudiArabia;KuwaitOilWellFires(air,soil,industrialhygiene) SouthernWatch19922002650Kuwait,Qatar,SaudiArabia(air,water,soil,industrialhygiene,bulk,asbestos)VigilantWarrior1994125Kuwait,SaudiArabia(air,water,soil,industrialhygiene) DesertFocus1996250SaudiArabia(air,water,soil,industrialhygiene,asbestos)JointEndeavorJointForge199620052,250Bosnia(air,soil,water) DesertThunder1998225Kuwait(air,water,soil)AlliedForce199925Albania,Macedonia(water,noise) JointGuardian19992005840Kosovo(air,soil,water,other)NativeAtlas1999100Kuwait(air,soil,industrialhygiene)EasternCastle200025Jordan(soil) NewHorizons19992006120DominicanRepublic,ElSalvador,Honduras,Nicaragua,Dominica,Guatemala,Guyana,Haiti,Panama(air,water,soil)JointInteragencyTaskForce(DrugInterdiction)19992006131Colombia,Ecuador,ElSalvador,NetherlandAntilles,Antigua,Belize,Bolivia,CostaRica,Guatemala,Nicaragua,Panama,Peru(air,water,soil)Tradewinds1999200619AntiguaandBarbuda,Barbados,DominicanRepublic,Ecuador,Jamaica,StKittsandNevis(water,soil) JointTaskForceBravo19992006125SotoCanoAirBase,Honduras(air,water,soil)EnduringFreedom200120061,590Afghanistan,Pakistan,Uzbekistan,Kuwait,Philippines,Cuba,Ethiopia,Kenya,Kyrgyzstan,Pakistan,SaudiArabia,Uganda,Uzbekistan(air,water,soil,industrialhygiene) IraqiFreedom200320065,503Iraq,Kuwait,UAE,Qatar(air,water,soil,industrialhygiene) JointTaskForceKatrina/Rita2005164Louisiana,Mississippi(air,water,soil)Total17,142

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AprilJune200657matterexpertshaveoftenaugmentedtheSMARTPMs,includingrecentmissionstoAfghanistan,ElSalvador,Haiti,HurricaneKatrina,Iraq,Kosovo,Kuwait,andUzbekistan.InportionsofUSCENTCOMsareaofresponsibility,concentrationsofairborneparticulatematterlessthan10mindiameterarepredominantlyatlevelsmuchhigherthannormallyencounteredintheUnitedStates.Theprimarysourceofthisparticulateappearstobewindblowndustandsand.Notenoughinformationiscurrentlyknownaboutthechemicalandphysicalcharacteristicstodeterminewhethershort-orlong-termhealtheffectscouldbeexpectedfromexposuretothesehighparticulateconcentrations.Therefore,DESPpartneredwiththeNationalOceanicandAtmosphericAdministration,NaturalEnvironmentalTestOffice,*USCENTCOM,andtheDesertResearchInstitute(DRI)forayear-longstudytobetterdistinguishtheparticulatematterbybothphysical(size,shape,geomorphology)andchemical(metals,elements,carbonratios,silicacontent)characterization.TheDRIwillcomparethisdatatoexistingdesertresearchdatafromOperationDesertStorm(1991)andotherUSandworldwidelocations.Fordeploymentlocationsrequiringmoreintensive,continuoussurveillance,theMobileAmbientAirMonitoringStationprovidescontinuoussurveillanceofUSEnvironmentalProtectionAgencycriteriapollutants,includingcarbonmonoxide,sulfurdioxide,nitrogenoxides,ozoneandparticulatematterlessthan10mindiameter.Thissuiteofequipmenttransmitsnear-real-timedataovertheinternet,allowingremotelylocatedDESPpersonneltocompileoperationalriskmanagementestimates.DESPandAirQualityProgrampersonnelprovideperiodiconsiteserviceindeploymentsettingstotrainpersonnel,installupgradedequipment,repositionthestationtoanewlocation,andestablishreal-timedeploymentOEHsurveillancedataconnectivity.Currently,onestationislocatedinaUSCENTCOMoperatinglocation.Otherstationsareavailablefordeploymentasrequired.Insummary,theongoingDESPmissionremainsoperationallyrelevantbyaugmentingtacticalpreventivemedicineassetswithdeploymentOEHsurveillance-uniquecollectionequipment,shipping,labanalysiscoordination,andinterpretation.ThesubsequentOEHORMestimateupholdstheArmyDOEHRMprogram,inwhichcommandersmakeinformeddecisionsaboutidentificationofdeploymentOEHhealthhazardsandriskmitigationmeasures.Armedwiththisknowledge,decisionmakerscansuccessfullyexecutetheiroperationalmissionwhileprotectingthehealthofdeployedforcesduringtheentirespectrumofthemilitaryoperations.Acknowledgement:JohnKolivosky,ChrisWeir,andJamesSheehycontributedinthepreparationofthis section. *ActivityoftheUSArmyDevelopmentalTestCommand (http://www.dtc.army.mil/capabilities/enviro.html) WatersamplinginIraq MobileAmbientAirMonitoringStationinKuwait SoilsamplingduringdeploymentinLouisiana(JointTaskForceKatrina)

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58ArmyMedicalDepartmentJournalPriortothereorganizationoftheDeploymentEnvironmentalSurveillanceProgram(DESP)in2004,informationtechnologydevelopmentandpolicyintegrationweretheresponsibilityofDESP.Asapartoftherestructuring,theDeploymentDataArchivingAndPolicyIntegration(DDAPI)Programwasestablishedtodevelopaninformationtechnologysystemcapableofcapturingandarchivingoccupationalandenvironmentalhealth(OEH)data,aspartofaComprehensiveMilitaryMedicalSurveillanceProgram.Thisprogram,illustratedschematicallyinFigure3,ismandatedbyDepartmentofDefense(DoD)directives,DepartmentoftheArmyPolicy,andJointStaffMemorandumtoensuretheeffectiveanalysisanddisseminationofdata.TheDDAPIisresponsibleasanagentoftheArmytoProvidefortheassemblingandarchivingofallDoDdeploymentandenvironmentalhealthsurveillancedataandreports.asrequiredbyDoDdirective.4(p5)Inaddition,theDDAPIProgramisresponsibleforintegratingOEHintoArmyPreventiveMedicinethroughtheDoctrine,Organization,Training,Logistics,Materiel,PersonnelandFacilitiesmodel,withprimaryemphasisontheDoctrine,TrainingandMaterielaspects.Tomeetthisresponsibility,theDDAPI,incoordinationwiththeDefenseOccupationalandEnvironmentalHealthReadinessSystem(DOEHRS)hasdevelopedtheOccupationalandEnvironmentalHealthDataPortal(OEH-DP).5TheOEH-DPisapasswordprotectedinternetsitethatallowsregistereduserstosubmitandretrievedocumentsandotherelectronicfilesassociatedwithOEHactivities.InadditiontomaintainingtheOEH-DP,theDDAPIProgramisresponsiblefordevelopinganinformationtechnologysystemtocapture,process,analyze,interpret,andreportallOEHdata.Examplesofthisdatainclude,butarenotlimitedto,environmentalsamples(air,water,soil),entomologicaldata,sanitationsurveys,andwastemanagementsurveys.Toaccomplishthis,DoDisexpandingthecurrentcapabilitiesofDOEHRSIndustrialHygiene(DOEHRS-IH)tocaptureandmanagethetypesofdataoutlinedabove.TheDDAPI,inconjunctionwittheotherarmedservices,isdevelopingthesystemrequirementsneededtoexpandthecapabilityofDOEHRS-IH.Thegoalistohaveasinglesystemforenvironmentalandoccupationalhealthsurveillancedataforbothdeploymentandgarrisonconditions.TheDOEHRS-IHisonlyonepartofcomprehensivemedicalsurveillanceandwillbelinkedtoothermilitaryhealthsystemssuchastheArmedForcesHealthLongitudinalTechnologyApplication.6Thesesystemswillworktogethertoprovidedalongitudinalhealthrecordforallmilitarypersonnelfromthetimetheyentermilitaryserviceuntiltheyseparate.Inaddition,theDDAPIisassistinginthedevelopmentandintegrationofdoctrine,training,andmaterialrequirementsforOEHfortheArmy.Theprogram,alongwiththeNavyandAirForce,workedtodevelopASTME2318-03,7whichstandardizestheprocesstoevaluatesitesusedbyUSmilitarypersonnel.TheDDAPIistheproponentforUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM)TechnicalGuides230and248.1,2TheDDAPIprovidesOEHtrainingtoawidevarietyofDoDagenciesandpersonnel.Thetrainingincludessamplingtechniques,operationalriskmanagement,entomologicalsurveillance,radiationprotection,riskcommunication,andsituationaltrainingexercises.ThetrainingisconductedusingawidevarietyofUSACHPPMsubjectmatterexpertsandiscoordinatedwithotheragenciesandarmedservicesforconsistencyacrosstheDepartmentoftheArmyandDoD.DEPLOYMENTDATAARCHIVINGANDPOLICYINTEGRATIONBradE.Hutchens HealthSurveillance MedicalSurveillance ComprehensiveMilitaryHealth Surveillance OccupationalandEnvironmentalHealthSurveillance Figure3.TheComprehensiveMilitaryHealthSurveillanceProgram

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AprilJune200659MaterialsolutionsaredevelopedtoassistpreventivemedicinepersonnelinthecollectionofOEHsamples.TheDDAPIpersonnelareconstantlyinvestigatingcommercial-off-the-shelfequipmentthatcanprovidemoreeffectiveandefficientwaystoacquireOEHdata.Also,existingsamplingmethodsarereengineeredtomeettheneedsofadeployedmilitaryforcebymakingexistingequipmentandsamplingmedialighter,smaller,simplertooperate,andmorerugged.Examplesofthisincludethedeploymentwaterandsoilsamplingkits(Figures4and5)andtheDeploymentEnvironmentalSurveillanceBackpack(Figure6).DDAPIpersonnelalsoparticipateinseveralDoDandinternationalworkgroups.ThisparticipationallowstechnologytobeleveragedacrosstheDoDandtheinternationalcommunity,bringingtogetherOEHsurveillancedatafromthroughouttheArmedServicesandInternationalcoalitionalpartners.Asdiscussedindetailinanaccompanyingarticle(page46),theDepartmentoftheArmysDeploymentOccupationalandEnvironmentalHealthRiskManagementprogrampolicyhas13majorelementsthatenablecommanderstobettermanagetheirresponsibilitiestominimizebothknownandpotentialdeploymentOEHexposurestoSoldiers,DepartmentoftheArmycivilians,andArmycontractors.AlloftheelementsrequireOEHdatatobecaptured,processed,analyzed,interpreted,andreported,whichisthemissionoftheDDAPIprogram.Acknowledgement:WilbertMoultrie,MarkWalter, KenyaJones,MaryRoso,WarrenWortmanandArtLeecontributedinthepreparationofthissection. REFERENCES1.TechnicalGuide230,GuideforDeployedPreventiveMedicinePersonnelonHealthRiskAssessment.Version1.3.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;2003.Availableat:http://chppm-www.apgea.army.mil/documents/TG/TECHGUID/TG230.pdf.2.TechnicalGuide248,GuideforDeployedPreventiveMedicinePersonnelonHealthRiskAssessment.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;2001.Availableat:http://chppm-www.apgea.army.mil/documents/TG/TECHGUID/TG248.pdf.3.DoDDirective6490.2,MedicalSurveillance.Washington,DC:USDeptofDefense;21October,2004.4.FieldManual100-14:RiskManagement.Washington,DC:USDeptoftheArmy;28April1998. Figure4.DeploymentPotableWaterSamplingKit Figure5.DeploymentSoilSamplingKit Figure6.EnvironmentalSurveillanceSamplingBackpack

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60ArmyMedicalDepartmentJournal5.USDeptoftheArmy.DOEHRSOEHPportal.Availableat:https://doehrswww.apgea.army.mil/doehrs-oehs/.Registrationrequired.6.OfficeoftheAssistantSecretaryofDefense(HealthAffairs),USDeptofDefense.AHLTA,Globalinformationforqualitycare.Availableat:http://www.ha.osd.mil/AHLTA/.7.AmericanSocietyforTestingandMaterialsInternational.ASTME2318-03:EnvironmentalHealthSiteAssessmentProcessforMilitaryDeployments.WestConshohocken,PA:AmericanNationalStandardsInstitute;2006.AUTHORS JeffreyKirkpatrickistheProgramManager,GlobalThreatAssessmentProgram,DirectorateofHealthRiskManagement,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround-EdgewoodArea,Maryland.LTCMoseristheProgramManager,DeploymentEnvironmentalSurveillance,DirectorateofHealthRiskManagement,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround-EdgewoodArea,Maryland.BradHutchensistheProgramManager,DeploymentDataArchivingandPolicyIntegrationProgram,DirectorateofHealthRiskManagement,USArmyCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround-EdgewoodArea,Maryland. THEUSARMYCENTERFORHEALTHPROMOTIONANDPREVENTIVEMEDICINE

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AprilJune200661Astimeschange,thedefinedrolesforsomemilitaryoccupationsmustalsochange.OnefieldwherethishasbecomeevidentisinthefieldofArmyPublicHealthNursing,AreaofConcentration(AOC)designation66B.Theneedfortransformationisapparentfromtherecentnamechangeforthe66B(PublicHealthNurse),previouslyCommunityHealthNurse.Traditionally,theroleoftheArmyPublicHealthNurse(APHN)hasbeendefinedintermsofprogrammanagementsets.TheAOCwasoriginallycreatedin1949torunaplannedprogramgearedtoassistnewparentsadjusttofamilylife,withtheoverallgoalofdecreasingemergencyroomutilization.Thescopeofpracticequicklywidenedtoprogramsfocusingonfamily-centeredservicesandcommunicablediseasecasemanagement.1Overtime,theAOC66Bincorporatedmanymoreprograms,includingtheidentificationorlabelingastheLatentTBInfection(LTBI)programmanager,theSexuallyTransmittedInfection(STI)clinicdirector,theHIV/AIDSprogramadministrator,thehealthconsultanttotheChildandYouthServices,ortheHealthPromotionCentermanager.OthermorelocalprogramtitlesmightbeIn-OutProcessingCentermanager,PregnantSoldierPhysicalTrainingProgramdirector,ortheSmallpoxVaccinationcoordinator.SometimesonemightwonderiftheAPHNisbeingaskedtofunctionasaspecialtypracticingnurseorasanurseprogramadministrator.TheincorporationofthepreviouslymentionedprogramsasresponsibilitiesoftheAOCisnotreallytheissue.TheAPHNcancertainlyfunctioninthoseareas,andshouldmaintainthoseduties.However,theyhavefoundthemselvespigeon-holedintothoseprogramroles.Manyofthoseresponsibilitiesarenotrequiredduringdeployment,orattheleastinafulltimecapacity.TheAPHNcouldbedeployedbeingcompletelyunsureofwhatwillbeexpected.Thisuncertaintyisunderstandablesincemuchoftheprevioustrainingandjobdescriptionshavebeengearedtowardsrunningthoseprograms.Amedicalcommandgroupwillnaturallyattempttooptimizeuseoftheirassetsinadeployedsetting.InthecaseoftheArmyPublicHealthNurse,theymustconsideranyvaluethatisrealizedwhenthisresourceisassignedthosetraditionalprogramsoftheAPHNingarrison.TheyknowthereisnoneedforachildandyouthhealthconsultantbecausetherearenoChildDevelopmentCenters.TheyarenotinterestedintheestablishmentofanHIV/AIDSprogram.TheyprobablydonotseetheneedforinandoutprocessingofSoldiersthroughthemedicaltreatmentfacility.STIandLTBIcanbefollowedintheacutecaresettinginacombatsupporthospitalorabattalionaidstationunderestablishedstandardoperatingprocedures.TheenvironmentofdeploymentprobablyexplainswhythedeployedAPHNisoftentaskedtofunctionwithinthescopeofthegeneralmedical-surgicalnurseAOContheintermediateortheminimalcareward.Thecommandoftenseesthattaskasthemostappropriateuseofanurseinadeployedenvironment.However,inmakingsuchassignments,commandersfailtofullyexploitthevaluableskillsofthePublicHealthNurse.TheroleoftheAPHNintheincreasinginvolvementoftheArmyinhumanitarianeffortsandcivil-militaryoperationsisanotherfactortoconsiderinArmyPublicHealthNursetraining.TheAOC66Bhasbeenproposedtofilltwoslotswithinacivilaffairs(CA)sectionoftheMedicalDeploymentSupportCommand.UndertheresponsibilitiesexpectedoftheCAsection,thereislittleneedfortheAPHNtofunctionwithinthetraditionalrolesorprogramsofthatAOC.Instead,theArmyPublicHealthNurseswillbeexpectedtoapplytheirskillsaspublichealthofficials.ItiswithinthisevolvingenvironmentthattheAPHNbasicskillsetmustchangetomeetthechangingneedsoftheArmy,butatthesametimemaintainMakingtheModernArmyPublicHealthNurse:EstablishingEssentialServiceSkillsMAJJamesA.Madson,MS,USALTCBryanJ.Alsip,MC,USA

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62ArmyMedicalDepartmentJournalfamiliarizationwiththetraditionalprogramsstillexpectedoftheAPHNingarrison.Toaccomplishthis,itisimportantthatwestartlookingattheAPHNprofession,notasprogrammanagers,butasskilledprofessionalsthathavemuchtobringtoPreventiveMedicine,ForceHealthProtection,andmilitaryoperations.Recently,leadershipintheAPHNfieldhasidentifiedthedirectiontotakeregardingtheAPHNfuturepractice.2TheyhaveestablishedavisionofreadyandfitSoldiersprosperinginhealthymilitarycommunities.Theoverallgoalistorealizethisvisionandtoalignthe66BAOCwiththeAmericanNursingAssociations(ANA)understandingoftheskillsetsrequiredbyapublichealthnursetoaccomplishthejob.FortheAPHN,thisskillsetshouldbeusedunderanynumberofsituations,includinggarrison,deployedsettings,civil-militaryoperations,andevenlocalemergencyresponseconditions.Theknowledge-basedskillsetrecognizedasthebasefoundationtopracticeasanArmyPublicHealthNursehascometobeknownastheAPHN-PublicHealthEssentialServices.The10servicesarebuiltdirectlyaroundtheworkoftheNationalPublicHealthPerformanceStandardsProgram.3Itsupportsthe3corepublichealthfunctions(assessment,policydevelopment,andassurance)modeledbytheAssociationofStateandTerritorialDirectorsofNursingPublicHealthNursingPracticeModel,4withtheintenttostandardizepracticeaccordingtotheANA.Theessentialservices,listedbelow,arethosethattheAPHNisexpectedtoperformunderanysituationrequiringcommunity-basedhealthinterventionsandpublichealthnursingefforts:1.Monitorhealthstatustoidentifycommunityhealthproblems.2.Diagnoseandinvestigatehealthproblemsandhealthhazardsinthecommunity.3.Informeducateandempowerpeopleabouthealthissues.4.Mobilizecommunitypartnershipstoidentifyandsolvehealthproblems.5.Developpoliciesandplansthatsupportindividualandcommunityhealthefforts.6.Enforcelawsandregulationsthatprotecthealthandensuresafety.7.Linkpeopletoneededpersonalhealthservicesandassuretheprovisionofhealthcarewhenotherwiseunavailable.8.Assureacompetentpublicandpersonalhealthcareworkforce.9.Evaluateeffectiveness,accessibility,andqualityofpersonalandpopulation-basedhealthservices.10.Researchnewinsightsandinnovativesolutionstohealthproblems.Toimplementtheseskills,itisimperativethattheinitialtrainingfortheArmyPublicHealthNurseincludesfundamentaldevelopmentandunderstandingoftheseessentialserviceexpectations.Presently,tobecomeanArmyPublicHealthNurse,aRegisteredNurseisrequiredtoattendthePrinciplesofMilitaryPreventiveMedicine(6AF5)coursewithintheArmyMedicalDepartment(AMEDD)CenterandSchool.Adjustmentshavebeenandcontinuetobemadetotheskillsetstraininginthe6AF5course,especiallythenursetrackphase,toaccommodatethisparadigmshiftinArmyPublicHealthNursing.Thegreatestchangecamein2003,whenanumberofhoursintheHIV/AIDScertificationmaterialwereremovedfromtheprogram.Thoughthetopicisrelevanttothe66BAOC,thedepthwasmuchgreaterthannecessarywhenviewedinlightofpracticalexpectationoffutureapplicationasanAPHN.Though6hoursofHIV/AIDSmaterialarestillprovided,eliminationofthisandsomeothermaterialfreedupnearly30hoursforadditionalcoursework. HealthfairsareperfectexamplesofhowArmyPublicHealthNursescaneducateandinformthepublicandmobilizecommunitypartnerships.Duringtheirtrainingincourse6A-F5,theAPHNsaredeeplyimmersedinthedevelopmentandpresentationofahealthfairwhichwilltypicallyhost200to300clientswith12to15vendors.

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AprilJune200663TheavailabletimeisusedtofocusontheessentialskillsetsandprojectedrolesoftheAPHNinadeployedsetting.Alongwithintroductiontosomeotherprograms,classesthatfocusedondevelopingskillsapplicabletopublichealthnursingwereincorporatedintothecurriculum.Traininginmanyskillswasexpanded.ClassesonthePlannedApproachToCommunityHealthandthePRECEDE/PROCEEDmodels5wereintroducedastoolsforcommunityassessmentsandsettinghealthobjectivesforthecommunity.ConductingacommunityhealthassessmentistheprimaryskillthattheAPHNwillneed.Theskillsetincludescollectionofdata,analysisofinformation,anddeterminingrisksandresourceswithinthepopulation.TheassessmentestablishesthefoundationofalltheotherAPHNresponsibilities.Theassessmentmustnotonlyconsiderthehealthofthepopulation,butalsorecreation,education,safety,andeconomics.TheprofessionalskillsbackgroundinnursingandtheabilityofnursestobuildpartnershipsandmobilizethecommunitymaketheAPHNassessmentdifferentfromotherPreventiveMedicineassessments.Additionalcoursesonetiologyandepidemiologyonmanyofthenewerdiseasesofmilitaryimportancearenowincludedtoimprovecompetenceinthiscriticalarea.Asampleoftheseusefultopicsincludesemerginginfectiousdiseases,suchasWestNilevirus,avianinfluenza,andleishmaniasis.Anothercontemporaryissueisexposuretobiologicalagentsandenvironmentalhazardsduringdeployment.ItisimportantthattheAPHNisabletodiscusstheseissuesinthemilitarycontext,andalsohaveanawarenessoftheconcernsofindividualswhofacepotentialexposure,aswellasthoseoffamilymembersworriedabouttheirSoldiers.TofacilitatethechangingroleoftheAPHN,completelynewmaterialwasintroducedintothecurriculum.TheAPHNnowreceives12hoursincivilaffairs,rapidhealthassessments,nutritionalconsiderationsindisasterrelief,preventivemedicinesupportincontingencyoperations,andPMoperationswithdetainees.ThiscoursematerialwasaddedtohelptheAPHNincorporatetheessentialservicesandpublichealthcorefunctionsintomilitaryoperationsotherthenwar,inparticularhumanitarianassistanceanddisasterrelief.ThematerialistheretostimulatestudentthinkingabouttheAPHNroleinadeployedsetting.Thestudentmustunderstandthatalthoughtheresponsibilitiesduringdeploymentsaredifferentinmanywaysfromthoseingarrison,basicskillsareappliedthesameway.TheAPHNmustassessthedeploymentsettingforriskandpotentialhealthconcerns,andidentifyresources.Interventions,programs,andpoliciesmustthenbeinstitutedtodecreasetherisksandtolinkspecificpopulationswiththeproperprogramsandresourcesintheareaofconcern.Lastly,thesettingmustbeevaluatedfortheeffectivenessofeffortsandchangesinthecommunity.Thepopulationmightbedifferent,buttheessentialserviceskillsetdoesnotchange. Duringthe6A-F5course,ArmyPublicHealthNursesworkwithotherPreventiveMedicineOfficersonissuesthattodaysSoldiermayfaceinadeployedsetting.Cross-training,thoroughinvestigations,andcommandbriefingsareemphasizedduringthetrainingperiod. ArmyPublicHealthNursetrainingoftenincludesunderstandingresponsibilitiesnottraditionallynursinginnature.Here,twostudentAPHNsidentifymosquitoesinanefforttomanageanotionalmalariathreat.

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64ArmyMedicalDepartmentJournalGoodpresentationskillsarenecessaryfortheAPHNtoinform,educate,andempowerpeople.Publicspeakingisvitaltoinformingcommandersofcurrentissues,instructingpersonneltoinsureacompetentpublichealthsystem,andsupportingregulations.ThepresentationsofmedicalthreatbriefsandaggregatehealthpromotioneducationaretheprincipalmeansforthepreventionofdiseaseandnonbattleinjuryintheArmy.TheAPHNexposuretopublicspeakingskilldevelopmenthasnearlydoubledwithrecentchangesinthenursetrackofthe6AF5course.Anotherincreasingroleforpreventivemedicineisinhomelandsecurityandlocaldisasterresponseplans.TheAPHNisnowgivenexposuretotheissueandmadeawareofthepotentialneedforpublichealthnurseinvolvementinresponseplandevelopmentandposteventaction.Theyaretaughtthiswithaspecialemphasisonbiologicalthreatresponses,communicablediseaseoutbreakresponses,andpreventivemedicinesupport.Onceagain,inthisenvironment,theAPHNmustbeabletoincorporatetheessentialserviceskillstomanagethecommunityunderanyofthepotentialsituations.Thereare,ofcourse,manyprevioustopicsinthe6AF5coursewhicharestillintegralpartsofthetrainingoftheAPHN.Someofthesebroadtopicsincludeepidemiology,outbreakinvestigations,occupationalandradiologicalexposures,environmentalquality,medicalentomology,datamanagement,andriskcommunication.Nomodificationshavespecificallybeenmadetothismaterial,butthenursesarechallengedtoseehowthismaterialisapplicablewithintheirscopeofpractice,andhowitrelatestotheessentialserviceskillsettheyareassimilating.TheAPHNalsoparticipatesinaPreventiveMedicineOperationandFieldTrainingExerciseattheendofthecourse.Theyareimmersedinasimulateddeployedsettingwithotherpreventivemedicinedisciplinesandareexpectedtoincorporatetheirproficiencyinissuesthatmightoccurinafieldenvironment.ThemodificationstoupdatetheroleoftheAPHNalsocomeatacriticallyvitaltimefortheAMEDD.ThecapabilitiesofofficersinotherprofessionalAOCswithinArmyPreventiveMedicineareenhancedbythedeploymentoftheskilledAPHNintheoperationalsetting.Whetheratacombatsupporthospitalorwithinacivilaffairsunit,theassessmentskillsoftheAPHNcanbeinvaluabletoothernurses,physicians,physicianassistants,andotherAOCs,includingEnvironmentalScienceOfficers(ESOs),EnvironmentalEngineers,Audiologists,NuclearMedicineScienceOfficers,andMedicalEntomologists.GreaternumbersofESOsarenowassignedatthebrigadeleveltoenhancesurveillancecapabilitieswithinadivision.TheAPHNcannowworkhandinhandwithESOsatthebrigadelevelandwithpreventivemedicinephysicianswhoareoftenassignedtothedivisionsurgeonsection.ThisallowstheAPHNtoactasaneffectiveforcemultiplierforpreventivemedicineinthissetting.ThechangesintheprogramhavebeengearedtowardthemodernizationoftheArmyPublicHealthNurse.TheAPHNbringseducationalexpertiseandprofessionalnursingskillsintotheArmyPreventiveMedicinearena.Theirbackgroundintheholisticnursingprocesshelpsfusetheenvironmentalaspectswiththeindividualfactorsassociatedwithpublichealth.Theyunderstandhumanresponsestoexposuresandtothediseasesthatmightoccur.Theycanbridgethegapbetweendataavailabilityandpracticalutilizationofthesedata.Thepublictendstotrustthenurseinsituationswheretheymightbereluctanttoacceptwordsandmessagesfromsomeoneelse.Therefore,theArmyPublicHealthNursesfindthemselveswellplacedinsituationstobringpublichealtheducation,compliance,andagreementonthefocusofpreventivemedicinetobenefitourmostimportantassettheSoldier.PublicspeakingasameansofinformingandeducatingthecommunityandassuringcompetencyamongotherhealthcareworkersisessentialinthedevelopmentoftheArmyPublicHealthNurse.

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AprilJune200665REFERENCES1.FieldManual8-24:CommunityHealthNursingintheArmy.Washington,DC:USDeptoftheArmy;10March1980.2.HollandsworthJE,HallTI,HartCM.CommunityhealthnursingintheArmy:past,present,andfuture.ArmyMedDeptJ.2005;PB8-05-7/8/9:21-24.3.ThePublicWorkforce:AnAgendaforthe21stCentury.Washington,DC:USDeptofHealthandHumanServices,PublicHealthService;1997.FullreportofthePublicHealthFunctionProject.4.AssociationofStateandTerritorialDirectorsofNursing:PublicHealthNursing:APartnerforHealthyPopulations.Washington,DC:AmericanNursesPublishing;2003.5.GreenL,KreuterM.HealthPromotionPlanning.2nded.MountainView,CA:MayfieldPublishingCo;1991.AUTHORS MAJMadsonistheAOC66BProgramDirectorintheDepartmentofPreventiveHealthServices,AcademyofHealthSciences,AMEDDCenter&Schools,FortSamHouston,Texas.LTCAlsipisthe6AF5CourseDirectorintheDepartmentofPreventiveHealthServices,AcademyofHealthSciences,AMEDDCenter&Schools,FortSamHouston,Texas. Thenewlogoemphasizesthemodernparadigmof todaysArmyPublicHealthNurseasaspecialty practicingnurse,notaprogrammanager.

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66ArmyMedicalDepartmentJournalINTRODUCTIONTheUSArmy's1stand9thAreaMedicalLaboratories(AMLs)providetheDepartmentofDefense(DoD)withaForceHealthProtection(FHP)capability.FHPisastrategyusingpreventivehealthtechniquesandemergingtechnologiesinenvironmentalsurveillanceandcombatmedicinetoprotectallservicemembersbefore,duringandafterdeployment.1ThemissionoftheAML:Onorder,deployworldwideandconducthealthhazardsurveillanceforbiological,chemical,nuclear,radiological,occupational/environmentalhealth,andendemicdiseasethreatsatthetheaterleveltoprotectandsustainthehealthoftheforceacrossthefullspectrumofmilitaryanddomesticsupportoperations.Throughtheuseofsophisticatedanalyticalinstrumentationcombinedwithhealthriskassessmentbymedicalandscientificprofessionals,theAMLperformsfieldconfirmationofenvironmentalexposuresassociatedwiththecontemporaryoperatingenvironment.Theexecutionofthismissionprovidesthewarfightingcommanderwiththecriticalinformationrequirementsneededtomitigateoreliminatehealththreatsduringtheoperationalriskmanagementprocess.The1stand9thAMLsaretheonlydeployablelaboratoriesintheUSArmy'sinventorycapableofprovidinghealthhazardsurveillancethrougharobustanalyticalcapability.BothAMLsareanEchelonAboveCorpslevelassetassignedto44thMedicalCommandandXVIIIAirborneCorps.Thisrelationshipexistsprimarilytoprovidecommandandcontrol,however,bothAMLscanprovideFHPsupporttoArmy,joint,orcombinedforces.TheAMLisauthorized43personnel,however,only30personnelarerequiredbytheModifiedTableofPersonnelandEquipmentandareavailableatalltimes.The13personnelnotpermanentlyassignedtotheunitarePROFIS(ProfessionalFillerSystem)assignedtoUSArmyMedicalCommand(MEDCOM)organizations.TheorganizationalstructureoftheAMLconsistsoftheHeadquarters,Occupational/EnvironmentalHealth,Nuclear/Biological/Chemical,andEndemicDiseaseSections.Theunitpersonnelrepresentawiderangeofscientificmilitaryoccupationalspecialties,therefore,boththe1stand9thAMLsarecapableofprovidingthecomprehensivehealthhazardsurveillancetypicallyassociatedwithMEDCOM'sfixedfacilities.ThehomestationoftheAMLsisEdgewoodArea,AberdeenProvingGround,Maryland.Thislocationwaschosenduetotherelianceofthe1stand9thAMLsonMEDCOMforsustainingSoldiertechnicalproficiency.TheAMLsdrawuponthefollowingorganizationsforthescientificexpertise,technicaltraining,assistance,andconsultation:USArmyCenterforHealthPromotionandPreventativeMedicine(USACHPPM),USArmyMedicalResearchInstituteforChemicalDefense(USAMRICD)WalterReedArmyInstituteforResearch(WRAIR)Duetotheproximatelocationtotheseorganizations,theAMLscaneasilyleverageandstaycurrentwiththeemergingtechnologiesnecessarytoperformtheirFHPmission.ForceHealthProtectionThroughLaboratoryAnalysisandHealthRiskAssessmentMAJPattersonW.Taylor,MS,USACOLScottW.Gordon,MS,USAMAJTaraL.Hall,MS,USAMAJGregoryL.Kimm,MS,USACPTStuartD.Tyner,MS,USACPTGeraldT.VanHorn,MS,USA

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AprilJune200667HISTORYTheArmyhasactivatedandinactivatedboththe1stand9thAMLsseveraltimes.BothlaboratoriessupportedcampaignsinWorldWarII.The1stAMLparticipatedininvestigationsinNorthAfricaandtheEuropeanTheatersofOperation.The1stAMLalsoparticipatedincampaignsoftheKoreanWarandtheVietnamWar.The9thAMLparticipatedintheChina-Burma-IndiaTheaterduringWorldWarIIandparticipatedin15campaignsintheVietnamWar.TheArmyactivatedthecurrentversionofthe1stand9thAMLsinSeptember2004.TheArmybasedbothAMLsonthestructureofthe520thTheaterArmyMedicalLaboratory(TAML)whichwasinactivatedonthesameday.Thehistoryofthe520thTAMLissimilartotheAMLswithparticipationcreditforVietnam,Bosnia,andOperationIraqiFreedom.Transformationofthe520thTAMLtothe1stand9thAMLsdidlittletochangethemission.TheArmyexpectsbothunitstoexecutethesamelevelofsurveillanceasthe520thTAMLperformedinsupportofOperationIraqiFreedom.Thechainofcommandforboththe1stand9thAMLsrunsthroughthe44thMedicalCommand,theXVIIIAirborneCorps,andtheUSArmyForcesCommand.TheArmypreservedthischainofcommandduringtheconversionfromthe520thTAML.ThepersonnelofbothunitsarelargelyenlistedSoldiersofthe91(nowchangedto68)militaryoccupationspecialtyseriesandasergeantmajoristhehighestrankingnoncommissionedofficer.Inadditiontothecommander,5officersprovideleadershiptotheAML.TheArmyequipsbothAMLswithtacticalequipmentthatenabletheunitstomoveandsurviveinatacticalenvironment.EachAMLhasorganictransportationassetsincluding5-tontrucks,FMTVs(FamilyofMediumTacticalVehicles),andHMMWVs(HighMobilityMultipurposeWheeledVehicles).TheAMLconductslaboratoryoperationsinTEMPERs(Tent,Extendable,Modular,Personnel),andIsolationFacilities.EachAMLcansupplyallthepowerneededforitsowncontinuousoperations.BothAMLsretainedheadquartersatAberdeenProvingGround,thelocationoftheformer520thTAMLsheadquarters.SincetheendemicdiseasesectionhasacloserelationshipwithUSArmyMedicalResearchInstituteforInfectiousDisease(USAMRIID),bothAMLsstationedthissectionoftheirunitsatFortDetrick,Maryland.TheAMLsretainedthesamecloserelationshipthatthe520thTAMLestablishedwithUSACHPPM,USAMRICDandUSAMRIID.Combined,thesecentersprovidemostofthetechnicaltrainingneededbyeachAML.ThesecentersalsoprovidePROFISpersonnelandcontroller/observerstoevaluatetheperformanceofeachAMLonfieldexercises.CAPABILITIESThepersonnelandequipmentorganizationalstructureoftheAMLplacesgreatchallengesupontheAMLtoperformlogisticalandmaintenanceoperations.BasedupontheModifiedTableofOrganizationandEquipment(MTOE),theAMLisapproximately35%mobile.Ifandwhencalledupontoprovidesupportinatheaterofoperation,theAMLwouldrequiretransportationassetstomoveallassignedequipmentandpersonnel.UnderthenewMTOEfollowingtheMedicalReengineeringInitiative,theAMLlostkeysupportmilitaryoccupationalspecialties(MOS)formerlyavailableinthe520thTAML.ThemostsignificantlossesweretheSupplySergeant(MOS92Y20),UtilitiesEquipmentRepairman(52C10),andtheMedicalEquipmentRepairman(91A20).TheAMLHeadquartersprovidescommandandcontrolfunctions,operationalplanning,administrativeandlogisticssupporttotheunit.Theheadquartersisstaffedbythecommander,executiveofficer,sergeantmajor,medicaloperationsofficer,medicalsupplysergeant,administrativespecialist,wheeledvehiclemechanic,andacook.OccupationalandEnvironmentalHealthSectionTheOccupationalandEnvironmentalHealth(OEH)SectionoftheAMLprovidescomprehensiveenvironmentalhealththreatassessmentsbyconductingair,water,soil,entomological,epidemiological,andradiologicalsurveillanceandlaboratoryanalyses.Insupportofthismission,theOEHSectionconductsanalysisin4areas:environmentalhealth,industrialhygiene,radiologicalassessment,andentomology.2-4TheOEHSectionmonitorsairqualityforparticulate,inorganic,andorganiccontaminants.TheSectionemployshighvolume,midvolumeandlowvolumeairsamplingequipmentcapableofcollectingparticulatesamplesPM-10(ParticulateMatter10m),PM-2.5(2.5m),TSP(TotalSuspendedParticulates),andinorganics(ie,heavymetals).Sorbenttubesandpolyurethanefoamsamplingsystemsareutilizedto

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68ArmyMedicalDepartmentJournalcollectambientandbreathing-zonesamplesofvolatileandsemivolatileorganics.TheOEHSectionpresumptivelydeterminesparticulatesamplesandsendstheseandinorganicsamplestoalaboratoryintheUnitedStatesforconfirmatoryanalysis.TheNBCSectionreceivesthesorbenttubescollectedbyOEHSoldiersandanalyzesthetubesusinggaschromatographycoupledwitheithermassselectivedetector,electroncapturedetector(ECD)orflamephotometricdetector(FPD).TheOEHSectionexecutescomprehensivewaterqualitysurveillance.TheOEHSectionconductsinorganicanalysisusingultravioletandvisiblelightspectroscopyandmeasuresmostinorganicwatercontaminantsabsorbancereadingstakenafteradditionofapplicablereagentsorinconjunctionwithotherisolationandextractionproceduresandreagentkits.TheOEHSectiondetects,identifies,andmeasuresconcentrationsofleadandcopperinpotablewaterwithanelectrochemicaldevicewhichutilizesanodicstrippingvoltammetry.Themethodisspecificforleadandcopperandisfreefromallknowninterferencestypicallyfoundinpotablewater.Organicanalysisisconductedusingeitheraportablegaschromatograph/massspectrometer(GC/MS)orabenchtopGC/MS/ECD/FPD.Todetectbacteriologicalcontaminationinwater,theOEHSectionutilizespresence/absencetechniques,membranefiltration,mostprobablenumber,andheterotrophicplatecounts.Tofurtheridentifynonfecalcoliformsorotherproblematicbacteria,theSectioncanforwardcollectedsamplestotheEndemicDiseaseSectionforanalysis.Soilsamplingandanalysisforthedetectionofvolatiles,semivolatiles,inorganics,metals,andbiologicalsisalsopossible.TheOEHSectionusestraditionalsoilsamplingequipmentandtechniquestoobtainsurfaceandsubsurfacesoilsamples.TheSectionhasthecapabilitytoconductsomelimited,on-the-spotcolorimetricandelectrochemicaltestingforPCBs(polychlorinatedbiphenyls)andPAH(polycyclicaromatichydrocarbons),butmostchemicalsoilanalysisisconductedbytheNBCSectionusinghead-spaceanalysiswiththeportableGC/MSorsolventextractionwithanalysisonthebenchtopGC/MS/ECD/FPD.TheOEHSectiondeploysarobustradiologicalsurveillancecapability.TheSectionusesnumeroushighvolumeparticulatesamplersandcollectsfiltersforradiologicalanalysis.TheSoldiersanalyzethesesamplesandcollectedsoilsamplesusingmultichannelscalingspectroscopy.TheSectionalsohasahandheldradiationspectrometer/identifier,dose-ratemeter,andnuclidefinderinadditiontomultipleradiacmeterswithprobesformeasuringalpha,beta,andgammaradiation.TheSectionanalyzeswipesamplesandwatersamplesusingaliquidscintillationcounter.TheSoldiersalsoemploydosimeterstomanagetheirownexposuresaswellasoccupationalexposuresofthoseworkinginandaroundradiationhazards.Further,besidesdetecting,identifying,andmeasuringionizingradiation,theSectionalsohasthecapabilitytodetectandmeasurenonionizingradiationhazards.TheOEHSectionconductsindustrialhygienesurveys.Usingmultigaselectrochemicalanalyzers,photoionizationdetectors,infraredgasanalyzers,andsamplingpumpswithfiltersand/orsorbenttubes,theSectionidentifiespotentialchemicalhazardsintheworkplace.Noisemeters,noisedosimeters,thermalenvironmentmonitors,ventilationmeters,andparticlecountershelptocharacterizethephysicalenvironmentandindoorairquality.UtilizingportableGC/MSandportableFourierTransformInfraredSpectroscopytechnology,theOEHSectionrespondsandqualitativelyidentifiesmanyunknownsolids,liquidsandgases.TheOEHSectioncontributesexpertiseinmedicalentomology,anothervitaldiscipline.TheSectioncollectsandidentifiesarthropods,rodents,andpoisonousplantsofmilitaryimportance,andalsoraisesmosquitolarvaeforaccuratespeciesidentificationorpotentialinsecticideresistancestudies.TheSectionpreparesandforwardsspecimenstotheEndemicDiseaseSectionforreal-timeortraditionalpolymerasechainreactionanalysistodetectandidentifymedicallyrelevantvector-bornediseases.

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AprilJune200669TheOEHSectionsstrengthistheabilitytoconductcompleteworksiteandambientenvironmentevaluationstodetectandidentifythehazardspresentinthefullspectrumofmedia,air,soil,water,physicalenvironment,arthropodsandrodents.Thesecomprehensiveevaluationsprovidethedatanecessarytoconductaccurateandthoroughenvironmentalhealthsiteassessments.NuclearBiologicalandChemicalSectionThecapabilitiesoftheNuclear/Biological/Chemical(NBC)Sectionincludecholinesteraseactivitymeasurement,microbialidentification,GC/MS/ECD/FPD,amobilelaboratoryandtelechemistry.ThesecapabilitiesallowtheSectiontomonitorforchemicalweaponsofmassdestructionandawidevarietyoftoxicindustrialchemicals,aswellastoconductmicrobialidentificationusinganindependentmethodthatcomplimentsthecapabilitiesoftheEndemicDiseaseSection.TheNBCSectionworkscloselywithboththeOEHandEndemicDiseaseSections.TheNBCSectionanalyzesmanysamplescollectedbytheOEHSection.Similarly,theNBCSectionanalyzesmicrobesculturedandincubatedbytheEndemicDiseaseSection.ThetechniciansoftheNBCSectionexecuteallofthecapabilitiesinanisolationfacility(ISOFAC).TheSoldierssetuptheISOFACusinganexpandable,2-sidedshelterattachedto2sectionsofTEMPER.SomeofthecapabilitiescanbeexecutedinthemobilelaboratorymountedinashelterunitonthebackofaM1097HMMWV.TheNBCSectionprovidesconfirmatoryanalysisofexposuretonerveagentsandtoxicindustrialcompounds(organophosphoruspesticides)bymeasuringacetylcholinesterase(AChE)activityinSoldierbloodsamples.TechniciansusetheTest-mateChETestSystem(EQMResearch,Inc,2814UrwilerAve,Cincinnati,Ohio,513-661-0560)toperformthetestsforAChE.TheabilityoftheTest-mateChETestSystemtodetermineAChEactivityunderfieldconditionswasevaluatedseveralyearsagobythe520thTAMLinconjunctionwithUSAMRICD.Tomimicnerveagentexposure,USAMRICDspikedbloodsampleswithvariableamountsofsoman.Blindedtotheidentityofthesamples,the520thTAMLtestedthesamplesduringafieldtrainingexercise.ThetechniciansaccuratelyidentifiedallofthesamplesandquantifiedtheAChEactivity.5TheNBCSectionprovidesconfirmatoryanalysisofmicroorganismsincludingaerobicbacteriaanaerobicbacteriaandyeastsusingtheMIDISherlockMicrobialIdentificationSystem(MIDI,Inc,125SandyDriveNewark,Delaware,800-276-8068).TheMIDIanalysissystemisbasedonfattyacidprofilesandcontainsreferenceprofilesforthousandsofmicroorganisms.ThistechniqueprovidesanidentificationthatisindependentfromothertechniquesusedbytheEndemicDiseaseSection.TheNBCSectionprovidesconfirmatoryanalysisofair,water,wipe,andsoilsamplesusinganAgilent6890NGC(AgilentTechnologies,Inc,395PageMillRoad,PaloAlto,California,6507525303).Thetechniciansextractwater,wipe,andsoilsamples.Massspectrafrequentlyprovideauniquefingerprintidentificationofchemicals.Usingtheretentiontimeandthemassspectrum,technicianscanoftenidentifyachemicalbasedsolelyontheresultsofGC-MS.Theotherdetectors,theECDandFPD,provideanalysisformuchlowerconcentrationsofthreatchemicals.TheECDdetectscompoundscontaininghalogensandotherelectronswithdrawinggroupsatlevelsmuchlowerthanthemassselectivedetector(MSD).TheFPDprovidesmuchgreatersensitivityforcompoundscontainingsulfurandphosphorousthantheMSD.SoldiersoftheNBCSectionalsoconductGC-MSwithaportableinstrumentcalledHAPSITE(Inficon,Inc,TwoTechnologyPlace,EastSyracuse,NewYork,315-434-1100).UsingtheHAPSITE,SoldierscancommenceanalysiswithlessthananhoursetuptimeThe520thTAMLconstructedamobileNBClaboratoryfromashelterunitmountedonaM1097HMMWV,equippedwithaGC-MS,gloveboxandRuggedizedAdvancedPathogenIdentificationDevice(IdahoTechnologyInc,390WakaraWay,SaltLakeCity,Utah,801736-6354)thermalcycler.6TheM1097HMMWVpullsatrailerwithamountedgeneratorthatsuppliesallthepowerneededtoconductsamplepreparationandGC-MSanalysis.Afulltankoffuelissufficienttopowerthegeneratorinnearlyaweekofcontinuoususe.ThemobilelaboratoryplatformgivesthecommanderoftheAMLmoreflexibilityinrespondingtoavolatileenvironment.TheAMLmobilelabcanconductsampleanalysismorerapidlyuponarrivalinanareaofoperations,usuallywithin3hoursofarrival,andcanperforminitialanalysisataremotelocationinsteadofwaitingforcollectedsamplestoarriveattheISOFAC.ThemobilelaboratoryprovidesthecommanderoftheAMLwiththeabilitytotestforchemicalandbiologicalagents,endemicdiseasesandtomonitorcholinesteraseactivityinSoldierswithpotentialfieldexposures.

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70ArmyMedicalDepartmentJournalThroughajointventurewithUSAMRICD,theAMLshavedevelopedthecapabilitytoconducttelechemistry.Throughasatellitelink,seniorscientistsatUSAMRICDcancontrolthecomputersthatruntheAMLsgaschromatographs,conductdataanalysis,tunetheMSD,troubleshoot,andevenrunsamples.Throughavideolink,USAMRICDscientistscaninspectsamplepreparationandidentifyotherproblemsthatrequirevisualinspection.TelechemistryprovidestheAMLsinadeployedenvironmentwithunprecedentedaccesstoscientistswithyearsofexperienceinanalyticalchemistry.7EndemicDiseaseSectionUponrequest,theEndemicDiseaseSectiondeploysworldwidetoconducthealththreatsurveillanceforbiologicalwarfareagentsandendemicdiseasethreatsatthetheaterlevelandprovidesandsustainsFHP.TheEndemicDiseaseSectioniscomposedofanofficer-in-charge(captainormajor,microbiologist[MOS71A]),anoncommissionedofficer-in-charge(staffsergeant[91K30]),and4medicallaboratorytechnicians(MOS91K).TheSectionsetsupitslaboratoryinanISOFACthatisnearlyidenticaltothatusedbytheNBCSection.TheSectionisself-supporting,withthecapacitytotransporttacticalandtechnicalequipment,provideenvironmentalcontrolandpowergenerationequipmentinordertocompleteanyassignedmission.TheEndemicDiseaseSectionreliesprimarilyonnucleicacidandantigendetectionbasedtechnologies,alongwithbasicmicrobiologicaltechniquesinordertodetect,identify,andanalyzenaturallyoccurringinfectionsandbiologicalwarfare(BW)agentsthatmaybeencounteredduringdeployments.TheSectioncanalsoconductlaboratorydiagnosisofmilitaryrelevantinfectiousdiseaseswhichareendemicwithinthetheater.However,inordertoenhancethecapabilitiesofthesection,PROFISpersonnelareassigned,includingaveterinarypathologist,veterinarymicrobiologist,preventativemedicinephysician,andaninfectiousdiseasephysician.WiththePROFISpersonnel,theSectionservesasthelocaljointtaskforcecommanderssubjectmatterexpertsonmattersregardinginfectiousdiseaseandBWagents,providinglaboratorysupportforin-theaterinfectiousdiseaseoutbreakinvestigations,andprocessingandanalyzingpotentiallydangerousinfectiousspecimens.Currently,thenucleicacididentificationcapabilities/technologyreliesontheRuggedizedAdvancedPathogenIdentificationDevice(R.A.P.I.D).Thesystemutilizesquantitativereal-timepolymerasechainreactiontechnologyandprovidesbothpresumptiveandconfirmatoryanalysisofpotentialBWandendemicdiseaseagents.ThesystemconsistsoftheR.A.P.I.D.analyzer,alaptopcomputerforprogrammingtheanalyzer,andbackpackforefficientstorageandeaseoftransport.Associateddurableequipmentconsistsofthenucleicacidextractionkits,amicrocentrifugeforcentrifugationof1.5mlsnap-captubes,andastandardcolorprinter.Thetechnologyisbasedonthedetectionofafluorescentreporterfluorochromeattachedtoaninternalprimerthathybridizestothetargetsequencebetweentraditionalforwardandreverseprimers.Presently,ourBWnucleicacidconfirmatorydetectioncapabilitiesarelimitedtoapproximately8to10agents.Reagentsareselectedbasedonthediseasecausingagentsendemictoaparticularregionandwhatisavailablethroughsupportingresearchinstitutions,suchasUSAMRIID.Forantigendetectionbasedcapabilities,theEndemicDiseaseSectionemploystheM-SeriesM1Manalyzer(BioVerisCorp,16020IndustrialDrive,Gaithersburg,Maryland20877,800-336-4436),anantibody-antigenbasedidentificationsystem(sandwichimmunoassay)developedforthedetectionofavarietyofantigens/analytesfromsmallmolecules,proteins,andmicroorganisms.Thesystemiscapableofanalyzingrawliquidsamplessuchasblood,serum,andliquidbuffersfromajointbiologicalpointdetectionsystemorbiologicalintegrateddetectionsystemunit.Thetechnologyisbasedonelectrochemiluminescence.Samplepreparationtagsthetargettoemitlightwhenelectrochemicallystimulated.Presently,BWantigenconfirmatorydetectioncapabilitiesarelimitedtoapproximately9agentsusingtheM1Manalyzer,withexpandedcapabilitiesusinganEnzymeLinkedImmunosorbentAssay(ELISA).TheEndemicDiseaseSectionisalsocapableofprovidingbasiclaboratorysupportforweaponizedandendemicbacterialagentsandparasiticorganisms.Limitedculturecapabilitiesincludetheabilitytogenerateambientair,microaerophilic,andanaerobiccultureenvironments.Basicbiochemicalidentificationofmanyhumanpathogensandenvironmentalorganismscanbeperformed.ToenhancethiscapabilitytheDadeBehringMicroscanautoSCANsystem(DadeBehring,Inc,1717DeerfieldRoad,Deerfield,Illinois60015,847-267-5300)isemployedtoprovidedefinitiveidentificationofgrampositive

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AprilJune200671andgramnegativeorganisms.TheantimicrobialsusceptibilitiesoftheseorganismscanalsobedeterminedwiththeautoSCAN.Endemicparasiteidentificationcanbeperformedonfixedsampleunknownsandothersampletypes,suchasmalarialsmearsandarthropodvectors.Fluorescentandlightmicroscopyisavailableforpathogenanalysisthroughvariablestainingmethodologies,ie,Gramstain,Wright/Giemsastain,andspecializedfluorochromestainsforspecificpathogens.Whileingarrisonandasidefromtechnicalandtacticaltrainingexercises,theEndemicDiseaseSectionhashadtheopportunitytoassistDoDaswellasthelocalcommunitywiththepresentcapabilities.DuringApril-Mayof2005,boththe1stand9thAMLsweretaskedbyDoDtorepresenttheArmyinamulti-ServicejointexerciseduringtheinitialoperationaltestandevaluationoftheJointBiologicalAgentIdentificationandDiagnosticSystem(JBAIDS),atBrooksAirBaseinSanAntonio,Texas.TheJBAIDSisanucleicacidbasedlaboratoryinstrumentsystemthatprovidescommanderswithrapidandspecificidentificationofbiologicalthreatagents.Followinga10daytrainingcourse,theAMLswereinvolvedina10dayrecordtestthatevaluated4of8JBAIDSsystemsfornetworkperformance,survivability,interoperability,andlogisticalsupport.InAugust2005,the9thAMLprovided5SoldierstoassistUSACHPPMfor2weeksatFortAPHill,Virginia.TheSoldiersassistedintheidentificationofLoneStar,Black-Legged(Deer),andAmericanDogticksandusednucleicacidbasedtechnologiestoscreenforsucharthropod-bornediseasesashumanmonocyticehrlichia,Lymedisease,humangranulocyticehrlichia,andRockyMountainspottedfever.DISCUSSIONAlthoughneitherAMLhasbeendeployedsinceactivationinSeptember2004,bothunitsmaintainahighstateofreadinessbyconductingrealisticfieldtrainingexercisesandmaintainingarobustintramuraltrainingprogram.OneofthelargestchallengesinthecurrentoperatingenvironmentisthemaintenanceofacoreofSoldiershighlytrainedwiththerequisiteskillstooperateandmaintaintheadvancedtechnologiesfieldedbytheAMLs.Tothisend,theAMLsinvestconsiderableeffortinarrangingmission-specifictechnicaltrainingprogramsforindividualSoldiersincooperationwiththeirfixedfacilitypartners.Throughparticipationinstrategicworkinggroupsandscientificconferences,AMLpersonnelstayabreastofcurrentissuesinForceHealthProtection.Everyeffortismadetoupdateunitequipmenttoreflectthelatestdevelopmentsintechnologyandprovideabetterproducttotheircustomers.TheyalsoworktoestablishrelationshipsandinvestigatejointtrainingopportunitieswiththeArmyNationalGuardandorganizationsoftheotherarmedservicesthatperformsimilarmissions.Inadditiontothedoctrinaltheatersupportmission,theAMLsprovideanuntappedresourceofessentialcapabilitiestosupportcivilauthoritiesinhomelanddefensemissions,consequencemanagement,anddisasterreliefoperations.Ready,relevant,andreliable,the1stand9thAMLsstandpreparedtoassistwheneverandwherevertheyareneeded.REFERENCES 1.USDeptofDefenseresourcespage.ForceHealthProtectionwebsite.Availableat:http://www.ha.osd.mil/forcehealth/about/main.html.2.FieldManual4-02.12:HealthServiceSupportinCorpsandEchelonAboveCorps.Washington,DC:USDeptoftheArmy;2February2004.3.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000.4.ArmyTrainingandEvaluationProgram.ARTEP8-668(MRI)-30-MTP:MissionTrainingPlanfortheAreaMedicalLaboratory.Washington,DC:USDeptoftheArmy;3December2002.5.TaylorP,LukeyB,ClarkC,LeeR,RousselR.FieldverificationofTest-mateChE.MilMed.2003;168:314-319.

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72ArmyMedicalDepartmentJournal6.ShippeeRL.TheTAML/AMLconcept;lessonslearned/prescriptionforchange.ArmyMedDeptJ.2004;JulSep:65-68.7.SlifeH,WinstonJ.Telechemistry,projectinglaboratoryexpertisetoadeployedareamedicallaboratory.MilMedTech.2005;9.3:3-42. AUTHORS MAJTayloristheChief,NuclearBiologicalandChemicalThreatAssessmentSection,9thAreaMedicalLaboratory,EdgewoodArea-AberdeenProvingGround,Maryland.COLGordonisCommander,1stAreaMedicalLaboratory,EdgewoodArea-AberdeenProvingGround,Maryland.MAJKimmistheExecutiveOfficer,1stAreaMedicalLaboratory,EdgewoodArea-AberdeenProvingGround,Maryland.MAJHallistheChief,Occupational/EnvironmentalHealthThreatAssessmentSection,9thAreaMedicalLaboratory,EdgewoodArea-AberdeenProvingGround,Maryland.CPTVanHornistheChief,EndemicDiseaseSection,9thAreaMedicalLaboratory,FortDetrick,Maryland.CPTTyneristheChief,EndemicDiseaseSection,1stAreaMedicalLaboratory,FortDetrick,Maryland.

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AprilJune200673SUMMARYBetween1941and1944,over1,000troopstrainingatCampBullis,TXpresentedtotheposthospitalwithconcurrentfever,rash,adenopathy,andcytopenia.Ineachcase,thephysicalexaminationwasalsonotablefornumeroustickbites,suggestinganarthropod-borneinfection.Thesyndrome,coinedBullisfever,wasself-limiting,butconvalescencewasprotracted.InvestigationsimplicatedtheLoneStartick(Amblyommaamericanum)asvector,andanaggregateofsignsconsistentwithBullisfeverwasreproducibleinvolunteersandguineapigsinoculatedwithemulsifiedtickextract.However,serafrominoculatedsubjectsdidnotshowcross-reactivitywithknowntick-bornepathogens,andworkupofasolitarycasepresentingseveralyearslaterwassimilarlynondiagnostic.TheendofthewarheraldedasharpdeclineinthenumberoftroopstrainingatCampBullisandalsoanabruptendtothediseasebearingitsname.Althoughhighlyspeculated,theetiologyofBullisfeverwasneverproven,andadefinitiveretrospectivediagnosisisunlikely.Theclinicalspecimenscollectedduringtheepidemicarenolongerextant.Moreover,insecticideuse,drought,andpredationhavedecimatedtheregion'stickpopulation.Sixdecadesaftertheepidemic,Bullisfeverseemsfatedtoremainenigmatic.INTRODUCTIONInthespringof1941,UnitedStatesArmyphysiciansassignedtoBrookeGeneralHospital(presentlyBrookeArmyMedicalCenter)atFortSamHouston,TX,encounteredanumberofacutelyillSoldierssufferingfrom(an)obscurefebrilediseasewhichdefieddefiniteidentification.1Invariably,eachoftheseSoldiershadbeentrainingatnearbyCampBullis(anadjunctfieldsiteforFortSamHouston)inpreparationfordeploymentoverseas.CoinedBullisfever,theillnesswascharacterizedbytheabruptonsetoffeverandchills,leukopenia,headache,andlymphadenopathy.Eventually,over1,000cases(withonefatality)wouldbediagnosed.However,acausewasneverprovenandasrecentlyas1988speculationappearedintheliteratureaboutitsetiology.2CLINICALPRESENTATIONBullisfevertypicallycommencedwithsubjectivechillsandfeverfrom102-105F.Patientscomplainedofpostorbitaloroccipitalheadache,lassitude,prostrationand,occasionally,nauseaandvomiting;andweightlosswascommon(20poundsinonepatient).Thefeverpersistedfrom4to14days(average5days)withabruptdefervescence.However,convalescencewasprotracted.3Onphysicalexamination,patientspresentedwithregionalorgeneralizedlymphadenopathyandafleetingmaculopapularrashsimilartothatofendemictyphus.Moreover,multipletickbiteswerecommonlyevident.Inseverecases,splenomegalyandsubconjunctivalhemorrhagewerenoted.Atypicalcasedescriptionappearedinthemedicalliteraturein1943:(Thepatient)wasadmittedtotheBrookeGeneralHospitalonJune25,1942complainingofseveregeneralizedheadacheoffourorfivehoursduration.Hisfacewasflushedaswithfever,andheappearedacutelyill.Theonsetofillnesswassuddenwithnausea,vomitingandsevereheadache...HehadbeenatCampBullis,Texas,foroneweek,June13toJune20inclusive,andhadreturnedtoFortSamHoustonfivedayspriortotheonsetofsymptoms.WhileatCampBullis,hesufferednumeroustickandchiggerbites.Physicalexaminationrevealedflushedskinandevidenceofnumerousinsectbitesontheabdomenandthelegs.Moderatelymphadenopathywasfound.Otherwise,physicalexaminationgavenegativeresults.3BullisFever:AFleetingEpidemicofUnknownEtiologyLTCMichaelJ.Zapor,MC,USA

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74ArmyMedicalDepartmentJournalAconstantfindingamongpatientswithBullisfeverwasleukopeniawithassociatedneutropeniaoccurringonoraboutthesecondorthirddayofsymptoms.Thetotalwhitebloodcellcountfrequentlydroppedtoabout3,000/landoccasionallyaslowas1,750/l.Theleukopeniagraduallyresolvedduringconvalescence,however,arelativelymphocytosispersistedbeyonddischarge.Severalpatientshadtracealbuminuriaandnonewereanemic.3Typically,patientswithBullisfeversufferedamild,self-limiting,febrileillnessof710daysduration.Insomeinstances,however,thecoursewasmoresevere,characterizedbydebilitationandprotractedconvalescence.Onedeathoccurredwhichwasattributedtoagranulocyticanginaandsepsis.Inabout10%ofcases,atransientrashresemblingGermanmeasles,andattimes,typhus3appearedearlyinthedisease.Treatmentwasmostlysupportiveandconsistedofcodeine,aspirin,ice,rest,andfluids.THEARMYMEDICALDEPARTMENTRESPONSEFacedwithanepidemicofunknownetiology,theBrookeGeneralHospitalcommander,COLGeorgeC.Beach,petitionedtheSurgeonGeneraltodispatchspecialistsforconsultation.Consequently,3membersoftheBoardfortheInvestigationandControlofInfluenzaandOtherEpidemicDiseasesintheArmy(DrsKennethE.Maxey,NormanH.Topping,andJohnC.Snyder)arrivedatFortSamHoustonon8July,1942.Afterathoroughexaminationofthepatientsandtheirmedicalrecords,these3investigatorsconcludedthattheevidencesuggestedanassociationwithtickbites(thusgarneringthetentativedesignationoftickbitefever),however,neitherthecausativeagentnorthetickasvectorhadbeenproven.Threesuccessivepapersweresubsequentlypublisheddescribingthesyndromeandreportingtheresultsofpreliminarylaboratoryinvestigations.Onepaper,authoredby3cliniciansatBrookeGeneralHospital,depictedtheclinicalpresentationandimplicatedtheLoneStartick(Amblyommaamericanum)asvector.3Anotherstudy,conductedbytheArmy's8thServiceCommandLaboratory,describedtheinductionofanillnessresemblingBullisfeverinanimalsinoculatedwithclinicalspecimens.4Inthisstudy,aconsistentlow-gradefebrilereactionwasobservedinguineapigsafterintra-abdominalinoculationwithbloodorlymphtissuefrominfectedpatients.Biopsyspecimens,takenbothfrompatientsandinoculatedguineapigs,demonstratedsmallintracellularfuchsinophilicgranulesandrods,similarinmorphologytoRickettsiae.However,serafrominoculatedanimalsshowednocrossreactivitywiththeetiologicagentsofRockyMountedSpottedfever(Rickettsiarickettsii)orQfever(Coxiellaburnetii),norweretheseanimalsprotectedagainstchallengewithRrickettsii.Athirdpaper,anepidemiologicstudypublishedataboutthesametime,reiteratedthelikelihoodofAamericanumasthevectorforBullisfever.5Collectively,thesestudiessuggestedthatBullisfeverrepresentedapreviouslyunknownrickettsialillnesswiththeLoneStartickaslikelyvector.Pursuanttothesefindings,theArmyscaledbackthenumberoftroopsdeployedtoCampBullisfortrainingwithaconsequentdecreaseintheincidenceofdisease.In1944,forexample,therewere47patientsadmittedwithBullisfevertoBrookeGeneralHospital,comparedtomorethan500casestheprecedingyear.1Interestingly,13ofthesepatientsweretreatedwithpenicillinwithouttherapeuticbenefit,furtherimplicatingarickettsialetiology.In1946,Armyresearchersfromthe8thServiceCommandLaboratoryandBrookeGeneralHospitalpublishedtheresultsofseveralhumanchallengeexperiments.6Inthesestudies,volunteerswereinoculatedwitheitherwholebloodfromnaturalcasesofdisease,wholebloodfromanaturalcasepropagatedthroughchickembryos,oranemulsionderivedfromthespleensofmiceinoculatedwithemulsifiedAamericanumticksfromCampBullisandseriallypassedthroughchickembryos.TheseresearchersfoundthatasyndromeresemblingBullisfevercouldbereproducedinhumansbyinoculationwitheitherwholebloodfromnaturalcasesorwithemulsifiedAamericanumticks.Basedonthesefindings,theydeterminedBullisfevertobeatransmissibleillnesswithacausativeagentmaintainablebyserialpassage.CONSIGNEDTOHISTORYWiththeendofWorldWarII,andafurtherreductioninthenumberoftroopspassingthroughCampBullis,thesyndromebearingitsnamebecameallbutforgotten.In1949,however,acasereportofBullisfeverwaspublishedbyphysiciansatWalterReedArmyHospitalinWashington,DC.7Thepatient,whohadtrainedpreviouslyatCampBullis,presentedwith

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AprilJune200675fever,leucopenia,andlymphadenopathy.Subsequentworkup,whichincludedcomplementfixationtesting,excludedAmericanQfever,RockyMountainSpottedfever,rickettsialpox,ColoradoTickfever,lymphocyticchoriomeningitis,andmumps.Interestingly,thepatientfailedtorespondtosulfadrugsandpenicillinbutshowedclinicalimprovementwithpara-aminobenzoicacid,anagentthenusedinthetreatmentofrickettsialdiseases.Subsequenttothatcasereport,therewasadearthofreferencestoBullisfeverintheliteratureuntil1975,whenAnigsteinandAnigsteinpublishedareviewofthesubjectandproposedthenameRickettsiatexianaforthehithertounnamedetiologicagent.8Morerecently,GoddarddescribedanairmanwithaclinicalsyndromeresemblingBullisfeverandpositiveserologyforEhrlichiosiscanis,promptinghimtospeculatethathumanehrlichiosisandBullisfevermightbethesamedisease.2Inreply,however,EngetaloftheCentersforDiseaseControldisputedthisconclusion,citingdifferencesinclinicalpresentation,hematologicparameters,histopathology,andendemnicity.2Specifically,theynoted:1.theassociationofgeneralizedlymphadenopathywithBullisfeveranditsabsenceinhumanehrlichiosis,2.theneutropeniaandlymphocytosiscommonlyseenwithBullisfever,contrastedwiththethrombocytopeniaandlymphopeniatypicalofhumanehrlichiosis,3.thedifferingappearanceofintracytoplasmicinclusionsinpatientswitheachdisease,and4.theexclusivedistributionofBullisfevercasestoCampBullis,TX.EPILOGUESinceitwasestablishedin1917asatrainingsitefortroopsheadedforthewarinEurope,CampBullishasfunctionedasatacticaltrainingareafortheArmy,AirForce,andMarineCorps,aprisonerofwarcamp,areceptioncenterforinducteesaswellasaseparationcenterforSoldiersuponcompletionoftheirmilitaryservice,andevenasthebackdropforseveralmotionpictures(TheRoughRiders,1926andWings,1927).TheArmymaintainsasmallcadreofassignedpersonnel,andthereareseveraltenantunitsbasedatCampBullis.However,WorldWarII,aswithotherconflicts,precipitatedamassiveinfluxoftroopstrainingtherepriortodeployingoverseas.PerhapsthesuddenproximityofalargehumanpopulationandthepresumedtickvectorsetthestagefortheBullisfeverepidemic.Similarly,theabruptdisappearanceofthediseasemaybeduetothenearabandonmentofthecampattheendofthewar.Moreover,therehasbeenanotabledeclineinthetickpopulationatCampBullisoverthepast6decades.Thismayderivefromaggressivetickeradicationbythecadre,aprolongedregionaldroughtinthe1950s,9andtheappearanceinTexasofthefireant,apredatorofticks.10,11However,thoseconditions,whichsetthestagefortheepidemic,mayeventuallyrecur,permittingthereemergenceofBullisfever.Asaconsequenceofcurrentandimpendinghostilitiesoverseas,thetempooftrainingatmilitaryinstallationsincludingCampBullishasintensified,12andmuchofthistrainingisconductedinforestedareaswithdenseunderbrush,terrainfavoredbytheLoneStartick.Moreover,someresearchersprojectresurgenceintheLoneStartickpopulationasaconsequenceofrisingpopulationsofthemammalianhostvectors(consider,forexample,thefiftyfoldincreaseinthenumberofwhite-taileddeerintheUnitedStatesduringthe20thcentury).13Collectively,thesevariablesmaycontributetotheeventualrecreationofthoseconditionswhichsetthestagefortheemergenceofBullisfever6decadesago.Untilthen,however,Bullisfeverisconsignedtohistoryasanintriguingdiagnosissansknownetiology.REFERENCES 1.AnnualReportoftheBrookeGeneralHospital,FortSamHouston,Texas.1942:21-24.2.GoddardJ.WasBullisfeveractuallyehrlichiosis?JAMA.1988;260;No.20:3006-3007.3.WoodlandJC,McDowellMM,RichardsJT.Bullisfever(LoneStarfever-tickfever).JAMA.1943;122:1156-1160.4.LivesayHR,PollardM.LaboratoryreportonaclinicalsyndromereferredtoasBullisfever.AmJTropMed.1943:475-4795.AnigsteinL.BaderKN.InvestigationsonrickettsialdiseasesinTexaspreliminaryreportoninvestigationsofBullisfever.TexasReportsonBiol&Med.Fall;1943.6.PollardM,LivesayHR,WilsonDJ,WoodlandJC.ExperimentalstudieswithBullisfever.AmJTropMed.1946;26:379-381.

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76ArmyMedicalDepartmentJournal7.ArnoldWT,VanNoateHF.Bullisfever:reportofacasetreatedwithPA-BA.BullUSArmyMedDept1949;9:218-223.8.AnigsteinL,AnigsteinD.AreviewoftheevidenceinretrospectforarickettsialetiologyinBullisfever.TexasRepBiolMed.1975;33;No.l:203-211.9.Heatwavesanddrought:legacyofaTexassummer.In:BomarGW,ed;TexasWeather.1sted.Austin,TX:UniversityofTexasPress,1983:143-156.10.BurnsEC,MelanconDG.Effectofimportedfireant(Hvmenopteraformicidae)invasiononLoneStartick(Acarinaixodidae)populations.JMedEntomo.1977;14:247-249.11.DreesB.Spreadoftheimportedfireant.AgNews[serialonline].Availableat:http://agnews.tamu.edu/graphics/fireants/antspred.htm.12.Armymedictraininghasgreaterurgency.TheDallasMorningNews.December23,2002.13.ChildsJE,PaddockCD.TheascendancyofAmblyommaamericanumasavectorofpathogensaffectinghumansintheUnitedStates.AnnuRevEntomol.2003;48:307-337.AUTHOR LTCZaporisastaffphysicianoftheInfectiousDiseasesService,DepartmentofMedicine,WalterReedArmyMedicalCenterWashington,DC.HeiscurrentlydeployedastheBattalionSurgeonandInfectiousDiseasesConsultantwiththe10thBrigadeSupportBattalion,1stBrigadeCombatTeam,10thMountainDivision(LI),CampLiberty,Iraq.

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authors commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly whether potential conflicts do or do not exist. Auth ors should do so in the manuscript on a conflict-of-interest notification section on the title page, pr oviding additional detail, if necessary, in a cover letter that accompanies the manuscript. 2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this assistance, if any. 3. Investigators: Potential conflicts must be disclosed to study participants. Authors must clearly state whether they have done so in the manuscript. 4. Related to project support: Authors should describe the role of the study sponso r, if any, in study design; collection, analysis, and interpretation of data; writing the repo rt; and the decision to submit the report for publication. If the supporting source had no such involvement, the authors should so state. PROTECTION OF HUMAN SUBJECTS AND ANIMALS IN RESEARCH When reporting experiments on human subjects, authors must indi cate whether the procedures follo wed were in accordance with the ethical standards of the responsible co mmittee on human experimentation (institution al and national) and with the Helsinki Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether t he institutional and national guide for the care and use of laboratory animals was followed. GUIDELINES FOR MANUSCRIPT SUBMISSIONS 1. Articles should be submitted in digi tal format, preferably an MS Word docume nt, either as an email attachment (with illustrations, etc), or by mail on CD or floppy disk accomp anied by one printed copy of the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exce ptions will always be considered on a case-by-case basis. In general, 4 double-spaced MS Word pages produc e a single page of 2 column text in the AMEDD Journal production format. 2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles should conform to those guidelines as cl osely as possible. Abbreviati ons/acronyms should be limited as much as possible. Inclusion of a list of article acronyms an d abbreviations can be very helpful in the review process and is strongly encouraged. 3. A complete list of refere nces cited in the article must be provided with the manuscript. The following is a synopsis of the American Medical Associ ation reference format: Reference citations of published articles must include the auth ors surnames and initials, arti cle title, publication title, year of publication, volume, and page numbers. Reference citations of books must includ e the authors surnames and initials, b ook title, volume and/or edition if appropriate, place of publ ication, publisher, year of copyright, and specific page numbers if cited. Reference citations for presentations, unp ublished papers, conferences, symposia, etc, must include as much identifying information as possible (l ocation, dates, presente rs, sponsors, titles). 4. Either color or black and white photographs may be submitted with the manuscript. Color produces the best print reproduction quality, but please avoid excessive use of multiple colors and shading. Digital graph ic formats (JPG, GIF, BMP) and MS Word photo files are preferred. Prints of phot ographs are acceptable. Please do not send photos embedded in PowerPoint. Images submitted on slides, negatives, or copies of X-ray film wi ll not be published. For clarit y, please mark the top of each photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 5. The authors names, ranks or academic/certification credenti als, titles or positions, current unit of assignment, and contac t information must be included on the title page of the manuscript. 6. Submit manuscripts to: EDITOR, AMEDD JOURNAL ATTN MCCS DT 2419 HOOD ST STE C FORT SAM HOUSTON, TX 78234-7584 DSN 471-6301 Comm 210-221-6301 Email: amedd.journal@amedd.army.mil