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U.S. Army Medical Department journal

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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

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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

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

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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.

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Digital Military Collection

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preventivemedicine:thescienceandpracticeofHEALTHprotection AprilJune2008Perspective1MGRussellJ.CzerwChemicalDefenseAgainstBlood-FeedingArthropods4byDisruptionofBitingBehaviorCOLMustaphaDebboun,MS,USA;JeromeA.Klun,PhDTheDeployedWarfighterProtectionResearchProgram:9FindingNewMethodstoVanquishOldFoesCAPTStantonE.Cope,MSC,USN;COL(Ret)DanielA.Strickman,MS,USA;GrahamB.White,PhDSupportofFar-ForwardDiseaseSurveillanceOperationswithDeployable,21Real-TimeVector-BorneDiseaseAgentAnalyticCapabilityColJamesA.Swaby,BSC,USAF;JamesC.McAvinLevelIIIPreventiveMedicineinaCounterinsurgencyEnvironment25MAJDerekJ.Licina,MS,USAPreparingtheForcefortheChemical,Biological,Radiological,and36HighYieldExplosivesBattlefield;TodayandTomorrowLTCGaryMatcek,MS,USA;ScottCrail,MS;SFCCourtneyMoore,USA;JamesBernardoTheArmyPreventiveMedicineSpecialistinthe40MedicalEducationandTrainingCampusEraLTCDennisB.Kilian,MS,USA;SFCRoyeL.Patton,USA;HMCSWilliamAdams,USNMalariaRiskAssessmentfortheRepublicofKorea46BasedonModelsofMosquitoDistributionDesmondH.Foley,PhD;etalTheUSAirForceAerialSprayUnit:AHistoryof54LargeAreaDiseaseVectorControlOperations,WWIIThroughKatrinaMajMarkBreidenbaugh,BSC,USAFR;MajKarlHaagsma,BSC,USAFREvolutionoftheArmyHearingProgram62MAJScottMcIlwain,MS,USA;etalPerspectivesofMalariaandJapaneseEncephalitisintheRepublicofKorea67LTCWilliamJ.Sames,MS,USA;Heung-ChulKim,PhD;COL(Ret)TerryA.Klein,MS,USAHealthImplicationsofOccupationalEnvironmentalHealthSampling74ColeenWeese,MD,MPH

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LTGEricB.SchoomakerTheSurgeonGeneral Commander,USArmyMedicalCommandMGRussellJ.CzerwCommandingGeneral USArmyMedicalDepartmentCenterandSchool AprilJune2008 TheArmyMedicalDepartmentCenter&School PB8-08-4/5/6 0809205 GEORGEW.CASEY,JR 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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AprilJune20081TheDepartmentofDefensedefinesthetermforcemultiplierasAcapabilitythat,whenaddedtoandemployedbyacombatforce,significantlyincreasesthecombatpotentialofthatforceandthusenhancestheprobabilityofsuccessfulmissionaccomplishment.1Militaryplanners,strategists,andanalystsgenerallyusethetermasrelatedtofactorssuchastechnology,intelligence,training,tactics,terrain,etc.However,overthelastcentury,thescienceandpracticeofpreventivemedicineinthemilitaryhasitselfbecomeanincreasinglysignificantforcemultiplier.Nonetheless,thecontributionsofpreventivemedicineareoftennotrecognizedassuchfollowingsuccessfulmilitarycampaigns.Ontheotherhand,theabsenceofeffectivemeasuresareimmediatelyapparent,forallthewrongreasons.Inearly1943,followingtheextremelydifficultandcostlyopeningcampaignsagainsttheJapaneseinPaupauNewGuinea,GeneralMacArthurwastoldthat72%ofthecombinedAlliedforcewassick,60%withmalaria.Hisbriefresponseclearlycapturestheindisputablevalueofpreventivemedicineasaforcemultiplier:Doctor,thiswillbealongwarifforeverydivisionIhavefacingtheenemy,Imustcountonaseconddivisioninhospitalwithmalariaandathirddivisionconvalescingfromthisdebilitatingdisease.2GeneralMacArthursremarkswereindicativeoftheincreasingawarenessamongtoplevelcommandersofpreventivemedicinesvitalroleincombatoperations.Overtime,thatevolvingrealizationhasresultedintop-downemphasis,policies,andregulationstoinstitutionalizepreventivemedicineasanintegralpartoftheplanningandexecutionoftrainingandoperationaldeployments.3Fortunately,increasingawarenessofpreventivemedicinesroleintheimprovementofhumanhealthhasnotbeenlimitedtothemilitary.Governmentsatalllevelshaveestablishedpoliciesandregulatoryframeworks,committedresources,andconductedpublicawarenessprogramstargetedattheimprove-mentoftheoverallhealthoftheirpopulations.Aswithmostareasofmedicalscience,thepracticeofpreventivemedicinetranscendsthemilitary-civilianboundary.Inthisregard,militarymedicineisveryfortunatetohavebeenbothbeneficiaryofandcontributortoitsprogressovertheyears.ThisissueoftheAMEDDJournalfocusesonthescienceandpracticeofpreventivemedicinefromamilitaryperspective,whilefeaturingarticlesthatreflectthemutualbenefitstobothsidesfromtheoverlapofknowledge,practices,andpurpose.COLMustaphaDebbounandDrJeromeKlunopenthisissuewithastimulatingarticleexploringthebackgroundandcurrentscienceofsyntheticorganicchemicalarthropodrepellents.Asrelatedintheirarticle,theworldsfirsttrulyeffectiveinsectrepellentwasdevelopedinacollaborativeeffortoftheUSArmyandtheDepartmentofAgriculture,whichbeganduringWorldWarII.Theydetailthechemistryofwhatarecurrentlythe3mosteffectivecompoundsandtheexperimentsthatexplorethemechanismoftheirrepellency.Thisresearchisaprimeexampleofthetypeofpartnershipsbetweenmilitaryandcivilianthataresoeffectiveinthescienceofpreventivemedicine.Theimportanceofsuchcollaborationtothemilitaryisdemonstratedinthenextarticle.CAPTStantonCope,USN,andhiscoauthorsdescribetheDeployedWarfighterProtectionresearchprogram(DWFP),aninnovative,forward-thinkingDoDefforttotapintononmilitarytalentandresourcesinthesearchfornewwaysofprotectingourdeployedpersonnelfromPerspectiveMajorGeneralRussellJ.Czerw

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2www.cs.amedd.army.mil/references_publications.aspxvector-bornediseases.TheDWFPprovidesfundingtobothgovernmentandnongovernmentresearchprojectswhichareexploringnewandbetterwaysoftroopprotection.AlthoughtheDWFPisarecentinitiative,theresultshavebeenanever-increasinglevelofknowledgeinthesciencesinvolved,withattendantimprovedsophisticationintechniquesandprocedures,aswellasanumberofproductscreatedspecificallyfordealingwiththeinsectthreat.Knowledgeofthespecificdiseasethreatsinadeploymentareaiscriticalindeterminingthetypeofpreventivemedicinemeasureswhicharerequiredforforceprotection.Currentdatamayormaynotbeavailable,oraccurate,andobtainingsuchinformationhasalwaysbeenatime-consuming,multifacetedundertaking.ColJamesSwaby,USAF,andJamesMcAvinhavebeeninvolvedinthedevelopmentofasystemthatwillallowforwarddeployedunitstoassessthelocalthreatofvector-bornediseasesinreal-time,withoutdependenceonfar-awaylaboratories.TheirarticledetailstheVectorSurveillanceAnalyticSystem,avitallyimportantadvancementinourarsenalofweaponstoprotectthehealthofourWarriors.SincetheendofcombatinKoreain1953,thecharacterofmilitaryconflicthasevolvedfromtheclassicmodelofconventionalwarfarebetweenarmiesintooperationsagainstshadowy,low-tech,looselyorganizedinsurgencies.MAJDerekLicinahascontributedaprofound,well-researchedarticlethatspotlightshowcounterinsurgencyoperationsarerarelywonwithoverwhelmingfirepoweralone,butwithotheroperationstargetingtheconditionswhichprovidethebaseofsupportforthoseinsurgents.Preventivemedicinecanandshouldbeamajorcomponentofsuchoperations.Thisimportantarticleisdevelopedusingthehistoryofsuchconflictscombinedwithextensiveexperiencewithcurrentcounter-insurgencyoperationsinthemiddleeast.MAJLicinaproposesthoughtfulchangesindoctrine,organization,andtrainingofArmypreventivemedicinedesignedtosignificantlyimproveitscapabilitytodirectlycontributetolong-termcounterinsurgencyoperations.Theprinciplesandscienceofpreventivemedicinemayindeedbethesecretweaponthatwilleffectafavorableshiftinboththephysicalandideologicalenvironmentsofmodernmilitaryconflict.Anironicrealityoftheshiftinthecharacterofmilitaryoperationstothefluid,ill-defined,counterinsurgencyenvironmentistheincreasedpotentialfortheuseofunconventionalweapons,atalmostanytimeorplace.Insurgentshavenopolitical,moral,orethicallimitationstotheiractions,andarenotconcernedaboutrepercussions.Theirlackofsophisticationincreasesthepotentialdangerthatchemical,biological,radiological,orhighyieldexplosives(CBRNE)couldbeusedinalmostanyscenario,includingaccidentallyduringtransportorstorage.LTCGaryMatcekandhisteamfromtheCBRNESciencesBranchhavecontributedanarticledescribingboththetrainingofmedicalpersonneltocopewiththeevolvingthreats,andthedevelopmentofnewtoolsandprotocolstoenhancetheircapabilities.ThedangerrepresentedbyCBRNEweaponsisnotlimitedtothebattlefieldormilitaryinstallation.Theimportanceofthiscomponentofpreventivehealthsciencecannotbeoveremphasized.OneofthemanychangesstemmingfromthelatestroundoftheBaseClosureandRealignmentCommitteeactivityistheconsolidationofasignificantportionofArmy,Navy,andAirForcemedicalenlistedtrainingatFortSamHouston.TheMedicalEducationandTrainingCampusisaresultofthatinitiative.LTCDennisKilianandhiscoauthorsdescribeindetailthemeticulouscollaborativeprocessthatresultedintheplanforconsolidatedtrainingofenlistedpreventivemedicinepersonnel.Theirarticleprovidesinsightintotheplansforboththeacademicsyllabuschangesandthepersonnelandphysicalinfrastructurerequirementsnecessarytomaketheconceptareality.Evenafteryearsofintensiveresearchandcountermeasures,malariaremainsoneofthemostpersistent,anddeadly,vector-bornehealththreatsintheworldtoday.Assessmentoftheriskofmalariainagivengeographicregionisthefirststepinplanningtoaddressitsthreat.SincemalariaistransmittedsolelybyseveralspeciesoftheAnophelesmosquito,identi-ficationoftheactualandpotentialdistributionofthosespeciesinageographicareacouldbeavaluabletoolinthedevelopmentoftheriskassessment.DrDesmondFoleyandhiscoauthorspresentanewapproachtheydevelopedtomodelthedistributionofmalariavectors,usingtheUSmilitaryinstallationsontheKoreanpeninsulaastheareasofinterest.Theirdetailedandclearlypresentedarticledemonstratestheimmeasurablevalueofthesymbioticrelationshipofmilitaryandcivilianresourcesandtalentinthewaragainstvector-bornedisease.Theincreaseinthenumberandcapabilitiesofdata-gatheringsources,Perspective

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AprilJune20083THEARMYMEDICALDEPARTMENTJOURNALcombinedwithincreasinglysophisticatedanalysisandmodelingtechniquesarepowerfulweaponsinthehandsofdedicatedprofessionalssuchasDrFoleyandhisteam.Innovativeworksuchasthiswillcontinuetoevolve,tothebenefitofeveryone,everywhere.In1918,anairplanewasusedtodistributeinsecticideforthefirsttime.4Sincethen,aerialapplicationofpesticideshasbeenaninvaluabletoolforbothagricultureandpreventivemedicine.USAFRMajMarkBreidenbaughandMajKarlHaagsmahavewrittenanexcellentarticleaboutoneoftodaysUSmilitaryaerialspraycapabilities,theUSAFAerialSprayUnit(AFASU).Theirarticletracesthelonghistoryofthisversatileunit,anddescribesitsmultiplerolesinrespondingtobothmilitaryandcivilianrequirementsthroughouttheUnitedStatesandoverseas.Thearticlefocusesonlargeareainsectproblems,especiallymosquitoes,whichbecomeveryseriousintheaftermathofhurricanes.TheAFASUsresponsetoHurricaneKatrinainLouisianaisdetailedasanillustrationoftheextensiveplanningandclosecooperationbetweenthemilitaryandcivilianpreventivemedicineauthoritiesthatisrequiredtoensureatimelyandeffectiveresponse.Thearticleprovidesaninformativeoverviewofthisuniquecapability,andthehighlevelofprofessionalismofthosewhoperformthevitallyimportantmissions.Hearingissomethingthatmostofustakeforgranted,yetitisoneofthemostimportant,andmostvulnerable,ofoursensesinasurvivalsituation,includingcombat.Notsurprisingly,somelossofhearingisoneofthemostcommonconditionsamongmilitaryveterans.Extremelyloudnoiseisanunavoidablepartofmilitaryoperations,buthearinglossinnotinevitable.Intheirinformativearticle,MAJScottMcIlwainandhiscoauthorsprovideanoverviewoftheconditionsthatcontributetohearingloss,andstatisticsthatdemonstratethesurprisingextentofthatlossamongmilitarymemberstoday.Theydetailthevariousresearch,techniques,andequipmentusedtoaddressthishazard,whichhasresultedintheArmyHearingProgram,thecurrentstructuredesignedtoprovideeffectivelosspreventionservicesatalllocations,includingforwarddeployedareas.Thisarticlecontainsimportantinformationwhichshouldbeofinteresttoeveryone,militaryorcivilian.DespiteallofoureffortssincetheKoreanWar,malariaandJapaneseencephalitisremainvalidthreatsinKorea.LTCWilliamSamesandhiscoauthorshavecontributedanimportantarticledescribingthesituationfacedbyourWarriorsandtheirfamilies,aswellastheKoreanpopulationasawhole,andtheongoingeffortstocontrolthethreatposedbythetwodiseases.Thearticleispackedwithinformationaboutthecyclesofinfectionandtransmissionforeachdisease,thehoststhatharborthepathogens,andthecooperativerelationshipsbetweentheUSmilitarypreventivemedicinespecialistsandthevariousKoreanagenciesinactionstoaddressthesethreats.Asclearlyillustratedthroughoutthearticlesinthisissue,therearenoboundariestopreventivemedicinesimportancetohealth,whethercivilian,military,ornational.Atfirstlook,evaluationofthehealthofSoldiersreturningfromdeploymentwouldseemstraightforwardaphysicalexaminationfocusedoninjuriesandwhateverillnessestheSoldiermayhaveincurredduringthedeploymentperiod.However,theextentoffollow-onillnessesthatarearesultofdeploymentshasbeenrecognizedonlyrelativelyrecently.DrColleenWeesesarticleisaneye-openinglookatthecomplexitiesinvolvedinquantifyingtheproblemofenvironmentalhazards,andthemeasuresimplementedtoaddressthosehazardsforourdeployingWarriors.Theresultsincludeaprogramthatcollectsandcataloguesworldwideenvironmentaldataforareaassessments,asystemthatmaintainstheexposurehistoryofmilitarypersonnelthroughouttheirlifetime,andformalizedrequirementsforthesamplingandevaluationofair,water,andsoilfromthedeploymentarea.Mostimportantly,significantexposuresmustnowbedocumentedintheindividualmedicalrecord.DrWeesesarticledemonstratestheresponsivenessofthemilitarymedicalsystem,andtheextentofoureffortstoprotectthehealthofourdedicatedWarriors,whetherimmediateorlong-term.REFERENCES 1.JointPublication1-02:DoDDictionaryofMilitaryandAssociatedTerms.Washington,DC:JointStaff,USDeptofDefense;March4,2008.Availableat:http://www.dtic.mil/doctrine/jel/new_pubs/jp1_02.pdf.2.CoatesJB.CommunicableDiseases:Malaria.Washington,DC:USDeptoftheArmy;1963.PreventiveMedicineinWorldWarII;vol6:2.3.GatesMB.Preventionisthebestwaytohealth.ArmyMedDeptJ.April-June2006:3-6.4.http://entweb.clemson.edu/pesticid/history.htm

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4www.cs.amedd.army.mil/references_publications.aspxInmilitaryoperations,vector-bornediseasesandassociateddiscomfortcausedbybitingarthropodscanbelargelypreventedwithproperuseofpersonalprotectivemeasures,particularlyarthropodrepellents.Whenappropriatelyapplied,suchrepellentsarethefirstlineofdefenseagainstawiderangeofarthropod-bornepathogensandwillpreservethefightingstrengthofthetroops.Thebitesofarthropodstransmitmanyofthedisease-causingagentsthatcauseourmilitarythemosttrouble.ThesediseasescantakeSoldiersoutoftheaction,makethemmiserablysick,orevenkillthem.Inaddition,thediseasesandthearthropodsthattransmitthemareasmuchofathreatduringroutinefieldtrainingexercisesorhumanitarian/disasterassistanceoperationsasduringactualcombat.Arthropodrepellentsprovidemilitarycommanderswithaquickandinexpensivemeasuretoprotecttheforceinanymilitarysituation,nomatterhowquicklytheunitisinvolvedinaction.Theycanbeappliedeffectivelytopreventanyarthropod-bornedisease,whetherornotsurveillancehasidentifiedthepathogen.Arthropodrepellentsareoftentheonlymeansofprotectionagainstarthropod-bornediseasesincombatenvironmentswhenvectorcontrolmeasuresarenotpossible,orwhenthespeedofmilitarydevelopmentspreventstheuseofchemoprophylaxisorvaccines.Inaddition,commanderswillbeabletominimizeincidenceofanyvector-bornedisease,providingatacticaladvantageagainstanunprotectedenemyforcewhichdoesnothavethebenefitofaneffective,long-lastingarthropodrepellent.TheDepartmentofDefense(DoD)InsectRepellentSystemisavailableforusebyallmilitarypersonneltopreventarthropod-bornepathogensthatcausediseasessuchasmalaria,leishmaniasis,trypanosomiasis,scrubtyphus,WestNilefever,andLymedisease.AsshowninFigure1,therepellentsystemconsistsof3components:permethrinonuniforms(andbednets),deetonexposedskin,andproperwearoftheuniform.Whenusedproperly,thissystemwillpreventdisease,pain,andtheannoyancecausedbybitesofinsectssuchasmosquitoes,sandflies,ticks,andchiggers.TherepellentsystemiscriticaltotheArmyMedicalRegimentsmottotoConservetheFightingStrength,andisamissionessentialtaskcontainedinSoldierTrainingPublication21-1.1Further,DoDpolicymandatesthateverySoldier,Sailor,Airman,andMarinemuststrictlyfollowtheguidelinesandmethodsoftherepellentsystem.DetailsarefoundintheArmedForcesPestManagementBoardTechnicalGuide362andintheUSArmyCenterforHealthPromotionandPreventiveMedicinefactsheetontheDoDInsectRepellentSystem3andattheUSArmyMedicalDepartmentCenterandSchooldeploymenttrainingportalwebsite.4DoDoperatestheWalterReedArmyInstituteofResearchand5otherUSoverseaslaboratories:ArmedForcesResearchInstituteofMedicalSciences,ChemicalDefenseAgainstBlood-FeedingArthropodsbyDisruptionofBitingBehaviorCOLMustaphaDebboun,MS,USAJeromeA.Klun,PhD PermethrinonUniform DeetonExposedSkin ProperlyWornUniform ABasicTrainingTask DoDPolicy CriticalForYourHealth Figure1.TheDoDInsectRepellentSystem

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AprilJune20085Bangkok,Thailand;USArmyMedicalResearchUnit-Kenya,Nairobi;NavalMedicalResearchCenterDetachment,Lima,Peru;NavalMedicalResearchUnit-2,Jakarta,Indonesia;andtheNavalMedicalResearchUnit3,Cairo,Egypt.Theseresources,combinedwithcollaborationswiththeUSDepartmentofAgriculture,AgriculturalResearchServicesandtheAustralianArmyMalariaInstitute,placetheUSmilitaryinanoutstandingpositiontotestandevaluaterepellentsinthelaboratoryandinthefieldagainstvectorsofmanydisease-causingpathogens.Allhaematophagousarthropodpestssuchasfemalemosquitoes,sandflies,mites,blackflies,andticksrequireabloodmealtoproduceeggsandcompletetheirlifecycles.Malesdonotbloodfeed.Thus,thankfully,onlyhalfofthepopulationofsucharthropodspeciesarebitersandblood-feeders.Thebitingactivityoffemalesiscomplexandtheymaypreferablyfeedonlyonspecifichostssuchasreptilesorbirds.Insomespecies,thefemalesmayhavemultiplehostswhichoftenincludehumans.Itisthesearthropodspeciesofblood-feedersthataresimplyannoying,orrepresentvectorsofdangerouspathogenicdiseasesthatcaninjureorkill.Thediseasesvectoredaremanyandincludemalaria,leishmaniasis,dengue,yellowfever,WestNilefever,Lymeborreliosis,andspottedfevers.Throughouthistory,humanshavestruggledagainsttheblood-feedingarthropods,andthestrugglecontinuestodayinfullforce.Syntheticorganicchemicalshaveproveneffectiveininterferingwitharthropodblood-feedingbehavior,andcanofferpersonalprotectionagainstthebitesofnuisancepestsanddiseasevectorsbytopicalapplicationtoskinorclothing.5,6Severalnotablyeffectivesyntheticrepellentcompounds,thestructuresofwhichareshowninFigure2,are:N,N-diethyl-3-methylbenzamide(deet)(structure1),2-(2-hydroxyethyl)-1-piperidinecarboxylicacid1-methylpropylester(variouslyknownasKBR3023,Bayrepel,PicaridinorIcaridin)(structure2),and(1S,2S)-methylpiperidinyl-3-cyclohexene-1-carboxamide(SS220)(structure3).Eachoftheserepellentcompoundshasaninterestingdevelopmentalhistory,andeachisknowntointerferewitharthropodblood-feedingbehavior.Deetwasdevelopedin1954asanoutgrowthofanintensivesystematicchemicalsearchforsyntheticpersonal-protectionchemicalsthatbeganduringWorldWarIIwithacollaborativeeffortinvolvingtheUSDepartmentoftheArmyandtheDepartmentofAgriculture(USDA),BureauofEntomologyandPlantQuarantine.7,8Intheyearsfollowingitsdevelopment,deetbecamethestandardpersonalprotectionrepellentproductofchoiceforusebythegeneralpublicandmilitaryorganizationsworldwide.TheuseofdeetwassouniversalthatitbecameananthropogenicorganicchemicalpollutantinmanybodiesofsurfacewatersrangingfromtheTamaRiverinJapanandtheRhineRiverinGermany,tothewatersoftheNorthSea.9 NO CH3 CH3 N O H CH3 N O H N O CH3 H H N O CH3N OH O O H 1S,2'S 1R,2'S 1S,2'R 1R,2'R 1 2 1 3 2 4 5 6 1 2 3 4 5 6Figure2.ChemicalstructureofDeet,KBR3023,andthediastereo-isomersofAI3-37220.

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6www.cs.amedd.army.mil/references_publications.aspxIn1996,thediscoveryofKBR3023wasannounced,10andtheracemiccompoundwassubsequentlycommercializedworldwidebyBayer.Thiscompoundcontains2asymmetriccentersasindicatedinFigure2,structure2,and,therefore,theracemiccompoundiscomposedof4diastereoisomers.Preliminaryworkwiththeyellowfevermosquito,Aedesaegypti,indicatedthatthe1R,2SdiastereoisomerofKBR3023(RS-KBR3023)wasthemosteffectiveindeterringmosquitobiting.11TheKBR3023efficacymightbeimprovedbyusingthemostbiologicallyactiveformofits4stereoisomers.IndependentfieldandlaboratorybioassayswiththeracemicKBR3023generallyshowthatiteffectivelyreducedbitesofmosquitoes,sandflies,noseeums,andticks,andeffectivenessofthecompoundwasoftenequivalenttodeet.12-18InhumanvolunteerlaboratorybioassayswithAe.aegypti,wefoundthatdeetandSS220wereequallyeffectiveandmoreeffective,respectively,thanKBR3023insuppressingitsbiting.19The3repellentcompoundswereequallyeffectiveagainstAnophelesstephensi.InternetsearchesindicatethatLanxessandS.C.Johnson,respectively,areactivelyinvolvedinmarketingthiscompound.*Theracemic2-methylpiperidinyl-3-cyclohexene-1-carboxamidewasfirstidentifiedasaninsectrepellentbyMcGovernetal,20andtheUSDAassignedthecompoundthecodenumberAI3-37220.LikeKBR3023,AI3-37220contained2asymmetriccenters,andachiralsynthesisyieldedaracemicmixtureof1S,2'S,1R,2S,1S,2Rand1R,2Rdiastereoisomers(Figure2,structures3,4,5,and6).Theracemicmixtureprovedtobeeffectiveagainstthebitingbehaviorofawidevarietyofblood-feedingarthropods.21-29AstudyofthestereoisomersofAI-37220showedthatthe1S,2'Sstereoisomer(SS220)wasthemosteffectiveisomerofthefourinreducingbitesbyAe.aegypti,30anditissurmisedthatenhancedrepellenteffectscanberealizedthroughspecificformulationofthismostactivestereoisomer.ToxicologicaltestsindicatethatSS220isbiologicallypacificandamenabletodermalapplicationtodefendhumansagainstmanyblood-feedingarthropods.Deet,KBR3023,andSS220areamongthemosteffectivesyntheticrepellentcompoundsforprotectionagainstnuisanceandblood-feedingarthropodsthatvectorhumandiseases.Despitethewidespreadknowledgeoftheprotectivequalitiesoftheserepellentcompounds,17,19,31therewas,untilrecently,littleinformationavailableonhowthecompoundsmechanisticallyaffectwholeorganismbehaviorandtherebysuppressesthebiting.Aseriesofbehavioraltests32withAe.aegypti,An.stephensimosquitoesandthesandfly,Phlebotomuspapatasiinthepresenceofdeet,SS220,andKBR3023topicallyappliedtotheskinofhumanvolunteersshowedthattheinsectsweredeterredfromfeedingonandrepelledfromsurfacesemanatingthecompounds.Whenoffereda12cm2or24cm2areaofskin,onehalftreatedwithcompoundandonehalfuntreated,theinsectsfedalmostexclusivelyonuntreatedskin.Thesandfliesandmosquitoesdidnotatanytimephysicallycontactchemically-treatedsurfaces.Whentreatedanduntreatedskinareaswerecoveredwithcloth,insectslandedandbitonlythroughclothcoveringuntreatedskin.Theseobservationsprovidedevidencethatthechemicalsdeterredfeedingandrepelledinsectsfromtreatedsurfacesprimarilyasaresultofolfactorysensing.Whencloth,onehalfuntreatedandtheotherhalftreatedwithchemical,wasplacedoveruntreatedskin,insectsonlytouchedandspecificallybitthroughtheuntreatedcloth.Thisshowedthattheactivityofthechemicalsdoesnotinvolveachemicalskininter-action.Inthepresenceofanyofthe3repellentcompounds,nomatterhowpresentedtotheinsects,overallpopulationbitingactivitywasreducedbyaboutone-halfrelativetothecontrols.Theresearchindicatesthattheprotectionaffordedbydeet,SS220,andKBR3023againsttheinsectfeedinguponhumansismechanisticallyacombinedconsequenceoffeedingdeterrentandrepellenteffectsofthecompounds.Thebehavioralstudiesclearlyshowedthatall3compoundswereperceivedbyolfactorysensing,anditwascuriousthattheseman-madeandstructurallydifferentcompoundsprofoundlyinfluencedtheblood-feedingbehaviorofAe.aegypti,An.stephensi,andP.papatasiinsimilarways.Natarajanetal11conductedcomputer-assistedstereochemicalstructure-activityrelationshipandmolecularoverlaystudiesofSS220,KBR3023,anddeettoshowthatformsofcompoundspossessingthehighestlevelsofrepellentandfeedingdeterrentactivityeachhavesimilarthree-dimensionalstructuralmotifs.Thissuggeststhatthebiomacromolecule(s)responsiblefortheolfactory *Websites:http://www.bayrepel.com/bre/en/index.phphttp://www.autan.com/nqcontent.cfm?a_id=1ChemicalDefenseAgainstBlood-FeedingArthropodsbyDisruptionofBitingBehavior

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AprilJune20087THEARMYMEDICALDEPARTMENTJOURNALrecognitionofthecompoundsintheinsectsis(are)specificallysensitivetotheactivespace-matchingqualitiesofSS220,RS-KBR3023,anddeet.Thedevelopmentofnewbehaviorally-activechemicaltoolsforprotectionofhumansagainstblood-feedingdiseasevectorswillultimatelydependupontheextenttowhichthefundamentalnatureofthisprocessisunderstood.REFERENCES 1.SoldierTrainingPublication21-1,SoldiersManualofCommonTasks,Level1.Washington,DC:USDeptoftheArmy;14December2007.2.AFPMBTechnicalGuideNo.36:PersonalProtectiveMeasuresAgainstInsectsAndOtherArthropodsOfMilitarySignificance.Washington,DC:ArmedForcesPestManagementBoard,USDeptofDefense;April18,2002.Availableat:http://www.afpmb.org/coweb/guidance_targets/ppms/TG36/TG36.pdf.3.USACHPPMFactSheet:DoDInsectRepellentSystem.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine.June2007.Availableat:http://chppm-www.apgea.army.mil/documents/FACT/DODInsectRepellentSystemJustheFacts-June2007.pdf.4.DoDInsectRepellentSystem.DeploymentRelevantTraining.USArmyMedicalDepartmentCenterandSchoolDeploymentPortalwebsite.Availableat:http://www.cs.amedd.army.mil/deployment2.aspx#.5.PhilipCB,PaulJR,SabinAB.DimethylphthalateasarepellentincontrolofPhlebotomuspappataciorsandflyfever.WarMedicine.1944;6:27-33.6.StrickmanD,MillerME,LeeKW,etal.SuccessfulentomologicalinterventionagainstAnophelessinensis,limitingtransmissionofPlasmodiumvivaxtoAmericanSoldiersintheRepublicofKorea.KorJEntomol.2001;31:189-195.7.McCabeET,BarthelWF,GertlerSI,HallSD.InsectRepellents.III.N,N-diethylamides.JOrgChem.1954;19:493-498.8.CushingEC.HistoryofEntomologyinWorldWarII.Baltimore,MD:TheLordBaltimorePressInc;1957.9.KnepperTP.AnalysisandmassspectrometriccharacterizationoftheinsectrepellentBayrepelanditsmainmetaboliteBayrepel-acid.JChromatogr.2004;1046(1-2):159-166.10.BoeckhJ,BreerH,GeierM,etal.Acylated1,3-aminopropanolsasrepellentsagainstbloodsuckingarthropods.PesticSci.1996;48(4):359-373.11.NatarajanR,BasakSC,BalabanAT,KlunJA,SchmidtWF.Chiralityindex,molecularoverlayandbiologicalactivityofdiastereoisomericmosquitorepellents.PestManagSci.2005;61(12):1193-1201.12.BadoloA,OudraogoAP,Ilboudo-SanogoE,CostantiniC.EvaluationofthesensitivityofAedesaegyptiandAnophelesgambiaecomplexmosquitoestotwoinsectrepellents:DEETandKBR3023.TropMedIntHealth.2004;9(3):330-334.13.CarpenterS,EyresK,McEndrickI,etal.RepellentefficiencyofBayRepelagainstCulicoidesimpunctatus(Diptera:Ceratopogonidae).ParasitolRes.2005;95(6):427-429.14.CostantiniC,BadoloA,Ilboudo-SanogoE.Fieldevaluationoftheefficacyandpersistenceofinsectrepellentsdeet,IR3535,andKBR3023againstAnophelesgambiaecomplexandotherAfrotropicalvectormosquitoes.TransRSocTropMedHyg.2004;98(11):644-652.15.PerroteyS,Madulo-LeblondG,PessonB.LaboratorytestingoftheinsectrepellentKBR3023againstPhlebotomusduboscqi(Diptera:Psychodidae).ParasitolRes.2002;88(7):712-713.16.YapHH,JahangirK,ZairiJ.Fieldefficacyoffourinsectrepellentproductsagainstvectormosquitoesinatropicalenvironment.JAmMosqControlAssoc.2000;16(3):241-244.17.FrancesSP,CooperRD,WatersonDGE,BeebeNW.FieldevaluationofrepellentformulationscontainingdeetandpicaridinagainstmosquitoesinNorthernTerritory,Australia.JMedEntomol.2004;41(3):414-417.18.PretoriusA-M,JenseniusM,ClarkeF,RingertzSH.RepellentefficacyofdeetandKBR3023againstAmblyommahebraeum(Acari:Ixodidae).JMedEntomol.2003;40(2):245-248.19.KlunJA,KhrimianA,MargaryanA,KramerM,DebbounM.SynthesisandrepellentefficacyofanewChiralPiperidineanalog:comparisonwithdeetandBayRepelactivityinhuman-volunteerlaboratoryassaysagainstAedesaegyptiandAnophelesstephensi.JMedEntomol.2003;40(3):293-299.20.McGovernTP,SchreckCE,JacksonJ.Mosquitorepellents:alicyclicamidesasrepellentsforAedesaegyptiandAnophelesquadrimaculatus.MosqNews.1978;38:346-349.

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8www.cs.amedd.army.mil/references_publications.aspx21.CarrollJF,SolbergVB,DebbounM,KlunJA,KramerM.ComparativeactivityofdeetandAI3-37220repellentsagainsttheticksIxodesscapularisandAmblyommaamericanum(Acari:Ixodidae)inlaboratorybioassays.JMedEntomol.2004;41(2):249-254.22.DebbounM,StrickmanD,GlassJA,etal.LaboratoryevaluationofAI3-37220,AI3-35765,CIC-4,anddeetrepellentsagainstthreespeciesofmosquitoes.JAmMosqControlAssoc.1999;15(3):342-347.23.DebbounM,StrickmanD,SolbergVB,etal.FieldevaluationofdeetandapiperidinerepellentagainstAedescommunis(Diptera:Culicidae)andSimuliumvenustum(Diptera:Simuliidae)intheAdirondackmountainsofNewYork.JMedEntomol.2000;37(6):919-923.24.FrancesSP,CooperRD,PopatS,BeebeNW.FieldevaluationofrepellentscontainingdeetandAI3-37220againstAnopheleskoliensisinPapuaNewGuinea.JAmMosqControlAssoc.2001;17(1):42-44.25.FrancesSP,CooperRD,SweeneyAW.Laboratoryandfieldevaluationoftherepellentsdeet,CIC-4,andAI3-37220againstAnophelesfarauti(Diptera:Culicidae)inAustralia.JMedEntomol.1998;35(5):690-693.26.FrancesSP,CooperRD,SweeneyAW,PopatS.Fieldevaluationoftherepellentsdeet,CIC-4,andAI3-37220againstAnophelesinLae,PapuaNewGuinea.JAmMosqControlAssoc.1999;15(3):339-341.27.SolbergVB,KleinTA,McPhersonKR,BradfordBA,BurgeJR,WirtzRA.Fieldevaluationofdeetandapiperidinerepellent(AI3-37220)againstAmblyommaamericanum(Acari:Ixodidae).JMedEntomol.1995;32(6):870-875.28.RobertLL,ColemanRE,LapointeDA,MartinPJ,KellyR,EdmanJD.LaboratoryandfieldevaluationoffiverepellentsagainsttheblackfliesProsimuliummixtumandP.fuscum(Diptera:Simuliidae).JMedEntomol.1992;29(2):267-272.29.WalkerTW,RobertLL,CopelandRA,etal.Fieldevaluationofarthropodrepellents,deetandapiperidinecompound,AI3-37220,againstAnophelesfunestusandAnophelesarabiensisinwesternKenya.JAmMosqControlAssoc.1996;12(2PART1):172-176.30.KlunJA,SchmidtWF,DebbounM.Stereochemicaleffectsinaninsectrepellent.JMedEntomol.2001;38(6):809-812.31.CarrollJF,KlunJA,DebbounM.RepellencyofdeetandSS220appliedtoskininvolvesolfactorysensingbytwospeciesofticks.MedVetEntomol.2005;19(1):101-106.32.KlunJA,KhrimianA,DebbounM.RepellentanddeterrenteffectsofSS220,picaridin,anddeetsuppresshumanbloodfeedingbyAedesaegypti,Anophelesstephensi,andPhlebotomuspapatasi.JMedEntomol.2006;43(1):34-39.ChemicalDefenseAgainstBlood-FeedingArthropodsbyDisruptionofBitingBehaviorAUTHORS COLDebbounistheChief,MedicalZoologyBranchattheDepartmentofPreventiveHealthServices,AcademyofHealthSciences,USArmyMedicalDepartmentCenter&School,FortSamHouston,Texas.Dr.KlunisaResearchEntomologistattheInvasiveInsectBiocontrolandBehaviorLaboratory,UnitedStatesDepartmentofAgriculture,ARSBeltsvilleAgriculturalResearchCenter,Beltsville,Maryland.

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AprilJune20089TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoesCAPTStantonE.Cope,MSC,USNCOL(Ret)DanielA.Strickman,MS,USAGrahamB.White,PhD *DetailedinformationontheDWFPcanbefoundathttp://www.afpmb.org/dwfpresearch.htm.INTRODUCTIONTheDeployedWarfighterProtectionresearchprogram(DWFP)isaninitiativetodevelopandvalidatenovelmethodstoprotectUnitedStatesmilitarydeployedabroadfromthreatsposedbydisease-carryinginsects.1Vector-bornediseasessuchasmalaria,dengue,leishmaniasis,andchikungunyaareamongthemostimportanthealthrisksfacingdeployedtroops.Therearenovaccinesformanydiseasestransmittedbybitinginsects,somethodsininsectmanagementandcontrol,aswellaspersonalprotection,aretheprimarytoolsavailabletoprotecttroops.2-5DuringandfollowingWorldWarII,scientistsfromtheUSDepartmentofAgriculture(USDA)wereregularlyfundedbytheDepartmentofDefense(DoD)todevelopnewmethodsandmaterialsforcontrollingbitinginsects,particularlythosethattransmitdiseasestohumans.Thishighlysuccessfulcollaborationproducedtoolsthatarestillpartofourinsect-controlarsenaltoday.Examplesinclude:Deet(N,N-diethyl-3-methyl-benzamide),theprimaryingredientinthemajorityofinsectrepellentsavailabletoday.Ultralowvolumeapplicationofinsecticides,amethodologythatdistributesalimitedamountofchemicalperacrebyoptimizingthedispersionandconcentrationofsize-limiteddroplets,nowthestandardmethodusedbyspraytrucksdeployedtoprotectneighborhoodsagainstmosquitoes.Permethrin-impregnatedfabricsforpersonalprotectionagainstthebitesofticks,mosquitoes,andotherblood-feedingflyinginsects.Permethrinisasyntheticpyrethroidinsectrepellentthatisusedtotreatuniforms,bednets,tentage,andotherfabrics.Onaglobalbasis,manydiseasestransmittedbyinsectsareincreasingandspreading(eg,chikungunya,dengue,WestNilefever)orremainwidespreadandprevalent(eg,malaria,leishmaniases,trypanosomiases)despitevariablevectorcontrolefforts.ThissituationisdemonstratedinTable1.Also,increasingnumbersofspeciesofmedicallyimportantinsectsaredevelopingresistancetoinsecticidescommonlyusedtoday.Forstrategicreasons,therefore,thereisacriticalneedintheDoDforthetypesofproductsUSDAisuniquelyabletoprovide.TheDWFPisdesignedtonotonlyencouragetherapiddevelopmentofsuchproducts,butalsotoimprovethecapabilityofUSDAtoprovidelong-term,innovativesupporttomilitarypreventivemedicine.Inshort,itistheintentoftheDoD,throughtheDWFP,toprovidefundingtotheUSDAAgriculturalResearchService(ARS)toreinvigoratethismutuallybeneficialworkingrelationshipbetweenDoDandUSDA,particularlyasitpertainstoDWFP,asdefinedin2writtenagreements.7,8ADMINISTRATIONANDAREASOFEMPHASISOFTHEPROGRAMTheDWFPisadministeredbytheResearchLiaisonOfficeroftheArmedForcesPestManagementBoard.Theprogram,whichwasstartedinFiscalYear04,isfundedat$5millionperyear.ItconsistsofanoncompetitivefundingprocessforUSDAARS-basedresearch,andacompetitivegrantsprocessopentonon-USDAARSscientists.Upto$3millionperyearisgiventoUSDAARS,specificallytoNationalProgram104,dealingwithVeterinary,Urban,andMedicalEntomology.ThefundsarethendistributedtovariouslaboratorieswithintheUSDAsystemasdescribedbelow.Upto$1.4millionisawardedeachyearinnewcompetitivegrants.Theamountavailablefornew

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10www.cs.amedd.army.mil/references_publications.aspxstartseachyeardependsonhowmanyprojectsarecarriedoverfrompreviousyears.Grantsareawardedforupto$250,000peryear,forupto3years.ThecallforpreproposalsgenerallygoesoutaroundSeptember.ThesearethenreviewedbyaDWFPTechnicalCommittee,consistingof8to10members,civilianandmilitary,representingtheArmy,Navy,andAirForce.Basedonpreproposalreviews,investigatorsmaybeaskedtosubmitafullproposal.InNovember,theDWFPCommitteeconvenesfora2-dayreviewoftheUSDAresearchandtodeterminewhichnewcompetitivegrantswillbeawarded.FinalcompetitiveawardwinnersareusuallynotifiedinDecember.TheDWFPresearchportfolioisconcentratedin3specificareas:novelinsecticidechemistries/formulations,applicationtechnology,andpersonalprotectivesystems.Thefirstareaincludesdiscoveryofnewactiveingredients,testsofexistinginsecticidesonpestsandvectorsofpublichealthimportance,especiallymosquitoesandsandflies,andreformulationofexistinginsecticidestoimproveefficacyordelivery.INVOLVEMENTOFTHEUSDEPARTMENTOFAGRICULTURETheUSDAARShasbeenapartnerinDWFPsince2004,butcooperationbetweenthenationsagriculturalresearchandthemilitarygoesbackmanydecades.WorldWarIIwasauniquemomentinthisrelationship.Americanforceswerefacedwiththeusualdiseasechallengesofwarfare,but,forthefirsttime,scientificunderstandingandindustrialcapacitycombinedtoofferhopeofpreventingthosediseasescausedbyvector-bornepathogens.TheUSDABureauofEntomologyandPlantQuarantinelaboratoryinOrlando9targetedthefleavectorsofplague,thelousevectorsoftyphus,thechiggervectorsofscrubtyphus,mosquitoesincludingvectorsofmalariaandyellowfever,10aswellasbedbugs,cockroaches,flies,andticks.11Injustafewyears,thelaboratoryrefinedtheusesofDDT*asacontrolagentforpublichealthpestsandofrepellentchemicals(ethylhexanediol,dimethylphthalate,dimethylcarbate,indalone,andbenzylbenzoate)astopicalandclothingrepellents.WorkersattheBeltsvilleCenterinventedtheinsecticidal *1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethaneorDichloro-diphenyl-trichloroethaneVectorsDiseasesIncidence,PrevalenceMosquitoesMalariaWarmregionsdeathsinexcessofonemillionperyearLymphaticfilariasisWarmregionsinfectionsinexcessof200millionArboviruses(chikungunya,dengue,Japaneseencephalitis,RiftValleyfever,WestNilevirus,yellowfever,etc)SpreadingepidemicsincreasingFliesandroachesDysenteryGlobalandrepetitiveSandfliesLeishmaniasesFocalapproximately6millioninfectionsayearFleasPlagueWidespreadoccasionaloutbreaksBlackfliesOnchocerciasis(RiverBlindness)AfricaandAmericas:focallessthan10millioncasesTsetseAfricantrypanosomiases(SleepingSickness)Africa:focallessthan5millioncasesReduviidbugsChagasdiseaseAmericas:24millioncasesacross15countriesTicksandmitesBorrelioses,ehrlichiasetcWidespreadTable1.MajorGlobalVector-borneDiseases6SnailsSchistosomiasisWarmregionsApproximately200millioncases TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoes

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AprilJune200811THEARMYMEDICALDEPARTMENTJOURNALaerosolbomb12(precursorofallspraycans)formilitaryuseduringWWII,andcollaboratedwiththeOrlandoLabtoinventtherepellentdeet13in1947.TheUSDAcontinuedtocollaboratewiththemilitarythroughthe1970sand1980s,mostnotablyworkingoutthemeansforpermethrintreatmentofmilitaryuniforms.14-16Concentrationonmilitaryproblemsslowed,eventuallyreducedtothedevelopmentofrepellentactiveingredientsandimprovedtrappingsystems.TheDWFPeffortbroughtgreaterfocusin3ways.First,itprovidedsignificantfunds($3millionperyear)totheUSDAARSforresearch.Second,itdefinedthesubjectareasofmostinteresttothemilitary,namelynewtoxicantsforpublichealthpests,newapplicationequipmentforpesticides,andnewpersonalprotectionsystem.Finally,theDWFPestablishedmechanismsofcommunicationbetweenthemilitaryandtheUSDAARSthathavekeptbothsidesengagedintheconversationonthedirectionofresearchrequiredtoproduceproductsfortheprotectionofmilitarypersonnelfromarthropodsthattransmitpathogens.Duringthelast3yearswehaveconceivedandexecutedtheconceptofavirtuallaboratorythattakesadvantageofthecorestrengthsoftheUSDAARSateachofthelaboratoriestoestablishasmoothflowfordevelopmentofnewvectorcontrolproducts.Chemicaldiscoveryproceedsfromseveralstrategiesthatare,forthemostpart,basedonbasicscienceratherthanbulkscreening.Promisingcandidatesemergefrombioassays,leadingtomorecomprehensiveevaluationagainsttargetinsects.Oncewehavewhatwethinkisausefulchemical,weconsiderhowbesttouseitagainsttargetinsectsinanintegratedpestanddiseasemanagementprogram.Withthosegoalsinmind,wehaveinthepastapproachedindividualprivatecompaniesinordertoformapartnershipforfurtherdevelopment.Inthatcase,itisuptothecompanytoformulatetheactiveingredient.Recently,wehavebeenperformingresearchonformulation,reasoningthatapreparationclosertoproductstatusmaybemoreattractiveforindustrialdevelopment.WearealsoworkingonregulatoryissuesbyfundingapositiononpublichealthpesticideswithIR-4*,theUSDA-fundedentitythatsupportsregistrationofpesticidesforuseonspecialtycrops.17SomeUSDAARSlaboratoriesandinvestigatorshavehadonlyatemporaryinvolvementwithDWFP,dependingmainlyonwhetherthecoreagriculturalmissionoftheiruniteffectivelysynergizedthemilitarymissionofthefunds.Currently,thereare5laboratoriesthatreceiveDWFPfunding.Thefollowingsectionsdiscusssomeoftheworkunderwayinthoselaboratories.InvasiveInsectBiocontrolandBehaviorLaboratoryTheInvasiveInsectBiocontrolandBehaviorLaboratoryinBeltsville,Maryland,isthelaboratorythatfirstpatenteddeet13thedominantactiveingredientinAmericaninsectrepellents.Itcontinuestobewell-equippedtoperformanylevelofsyntheticandanalyticalchemistry,anobviousadvantageforalaboratoryattemptingtodiscovernewtoxicantsandrepellents.Chauhanandcolleagues18havebeeninvolvedinthediscoveryofpromisingnewrepellentactiveingredients,mosquitolarvicides,andexcitingnewinsecticidalchemistries.HetakesadvantageofasmallAedesaegypticolonyonsiteandperformssimple,screeningbioassaystoguidehiswork.Anotherresearchteamisatthecuttingedgeofresearchonhowmosquitoesdetecthosts.19Usingmolecularbiologyandelectrophysiology,theywilldeveloptoolsthatdissectbitingbehaviorintoitscomponent,physiologicalparts.Combinedwiththesyntheticchemistryofthelaboratory,thisworkwillprovideveryprecisepathwaysfordiscoveringentirelynewbehavior-alteringchemicals.Potentialproductscouldbechemicalsthatselectivelyrepelinfectedmosquitoes,chemicalsthatinducemosquitoestobitenonhumanhosts,andpowerfulattractantsthatcouldbecombinedwithtoxicants.MosquitoandFlyResearchUnitScientistsattheMosquitoandFlyResearchUnit(MFRU)inGainesville,Florida,areexpertsonmanyaspectsofthebiologyandcontrolofmosquitoesandflies.Theirworkincludesthefollowing: *InterregionalResearchProjectNo4(IR-4),theMinorCropPestManagementProgram,istheprincipalpubliceffortsupportingtheregistrationofcropprotectionproductsandbiologicalpestcontrolagentsforapproximately$40billionminorcropindustry.Source:USDACooperativeStateResearch,Education,andExtensionService,http://www.csrees.usda.gov/nea/pest/in_focus/ipm_if_minor.html

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12www.cs.amedd.army.mil/references_publications.aspxToxicantdiscoverybyPridgeonetal20includestestsofregisteredtoxicantsthathavenotyetbeenappliedforpublichealthpests.Theyalsoworkwithindustrytoexploretheeffectivenessofnewcompoundsthathavenotbeenusedasinsecticides.Promisingchemicalshavealsobeenextractedfromnativeplants.Pridgeonandassociates21haveinventedanentirelynewclassofmolecularpesticidesthatpromisetocombinegreatsafety,flexibility,andspecificity.22,23Bernierandcolleagueshaveextendedfundamentalworktotheproductionofinhibitorsformosquitoes(patentpending)andpowerfulattractantsforflies24andmosquitoes.25CollaboratorsattheUniversityofFloridaareusingcomputationalchemistry(QSAR/QSPR*)toreanalyzepesticidebioassaydatageneratedover50yearsattheOrlandoandGainesvillelaboratories,resultinginsynthesisofrepellentswith3-foldlongerrepellencythandeet.26ResearchersCooperbandandAllen27havealsoexploredtheeffectsofsublethaldosagesofpesticidesonmosquitobehaviorusingquantitativeinterpretationofvideos,extendingourknowledgeofhowbesttoapplyresidualinsecticides.Researchisunderwayonflycontrol,includingtrappingandtoxicants,atfieldsitesintheUnitedStatesandmiddleeasternlocations.TheCenterforMedical,Agricultural,andVeterinaryEntomology,whichincludestheMFRU,hasbeenveryactiveindevelopingfieldtestssites,includingThailand;Kenya;CampBlanding,Florida;andtheCoachellaValley,California.TheMFRUworkscloselywiththeNavyEntomologyCenterofExcellenceattheUSNavalAirStation,Jacksonville,Florida,especiallyforfieldtestingandevaluationofapplicationequipment.BiologicalControlofPestsResearchUnitAttheBiologicalControlofPestsResearchUnit(BCPRU)inStoneville,Mississippi,LynandStreett28collaboratewithscientistsattheMFRUandindustrytodevelopformulationsofpublichealthpesticides.Also,theBCPRUhasfacilitiesforpilotproductionofbiopesticides.NaturalProductsUtilizationResearchUnitTheNaturalProductsUtilizationResearchUnitinOxford,Mississippi,hasahistoryofworkinginpartnershipwiththeUniversityofMississippiSchoolofPharmacyonthediscoveryofnaturalsourcesofbioactivecompounds.Theunitgoesbeyondsimpleextractstocomplexanalysisoffamiliesofchemicalsandoptimizationthroughsynthesisofseriesofcompounds.ThankstoDWFPfunding,USDAwasabletoleveragetheeffortbytransferringfundstotheUniversityofMississippiforinsecticidedevelopment.Cantrellandcolleagues29,30havealreadybeeninvolvedindiscoveryandpatentofrepellentsandtoxicants.TheproductsoftheirresearchwillbescreenedonsiteusinganewandverysimplebioassaydevelopedbyBecnelandPridgeon31attheMFRU.PromisingcandidateswillbeevaluatedinmoredetailbytheMFRU.AreawidePestManagementResearchUnitHoffmannandassociates32,33attheAreawidePestManagementResearchUnit(APMRU)inCollegeStation,Texas,haveworkedcloselywiththeMFRUandtheNavyEntomologyCenterofExcellencetosystematicallyevaluatethedropletspectraofawiderangeofapplicationequipment.Thedatahavealreadyinformedthemilitaryonthebestequipmentforitspurposes.Also,Nachmans34completedworkonneuropeptidesofpublichealthpests,includingmosquitoes,ticks,andflies,hasestablishedanentirelynewpotentialmechanismforinsecticidalmodeofaction.COMPETITIVEAWARDHIGHLIGHTSPubliclypostedonthefederalgovernmentswebsiteannouncinggrantavailability,DWFPrequestsforpreproposalshaveyieldedanaverageof38submissionsannually,fromacademics,militaryentomologists,industry,andothersaroundtheworld.Morethanone-thirdofthesehavebeeninvitedtopreparefullproposals,fromwhich34projects,showninTable2,havebeenselectedforgrantfundingduringthefirst5yearsoftheprogram.Therangeoftopicsandthequalityofmanyproposalshavebeenimpressive.Indeed,manyoftheintendedproductscouldfindwiderapplicationsforpublichealthandveterinarypestcontrol.Sofar,thesmallestgrantvaluewas$22,552over2years,whilesomegrantshave *Quantitativestructure-activityrelationship/quantitativestructure-propertyrelationship http://www.grants.gov/TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoes

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AprilJune200813THEARMYMEDICALDEPARTMENTJOURNALAwardRecipientPurposeOrg*Highlights 2004(n=8)CDRClaborn(DrWalker)SprayerdieselconversionM2prototypes&NSNLTCColemanSandFlycontrol--IraqMImprovedfieldoperationsLCDRHoffmanMosquitocontrolwithUAVMPassedtoUSAFProfPhilKoehlerFilth&BitingFlycontrolA1NSN&2deployedcitationsDrBobPetersonComparativeriskanalysesAPublications&publicappreciationDrStevePresleyHollowfiberimpregnatedfabricANoveltechnologyDrBillReifenrathRepellentsynergyDCancelledDrEdRowtonSandFlycontrol--laboratoryMEssentialcollaborations 2005(n=7)ProfChasAppersonDenguevectorovitrapADutyunderinstructionstudentProfLaneFoilTargetedsandflycontrolAWRAIRcollaborationLTHaagsmaMosquitocontrolwithUAVMPassedtoUSDAARSAPMRUDrQueLanNovelmosquitoinsectgrowthregulatorAProductlicensedDrMikeScharfLowmolecularweightinsecticidesAIndustrysupportLTStancil(LCDRFlorin)DenguevectorlarvalcontrolMEPAregistrationinpreparationProfAlonWarburgSandFlycontrolmilitarycampsAWRAIRcollaboration 2006(n=6)BruceDorendorfDieselbackpackDNECE**collaborationBruceDorendorfUltralowvolumenozzleDNECE**collaborationDaveMaloneNewultralowvolumeadulticideetofenproxDEPAregistrationinprogressDrPhilKaufmanNovelcompoundsADutyunderinstructionstudentDrBobPetersonComparativeriskanalysesAStrategicappreciationDrGabyZollnerNovelvaporrepellentMDelayed 2007(n=3)DrEdRowtonSandFlycontrolWRAIRlaboratoryMEssentialcollaborationsMAJRichardsonSandFlyinsectary,USAMRU-KMPioneeringserviceDrDolan&DrMcAllisterNaturalproductpesticidesGCDC-NCZVEDcollaborations 2008(n=10)BruceDorendorfUltralowvolumebackpackdieselsystemDProfLaneFoilSandFlylarvalcontrolAMAJStephenFrancesAustraliafieldrepellentfabricsMPhilippKirschAdulticidestargetingSandFliesDProfPhilKoehlerMilitaryprotectionsvsFilthFliesARichardPocheHost-targetinsecticidesvsSandFliesDLTRichardsonNoveltools&strategiesvsAe.aegyptiMProfMasoudSalyaniSpraymethodsvsSandFliesAProfAlonWarburgPhlebotominecontrolADrMikeWillisFormulateUW4015larvicideDTable2.DeployedWarfighterProtectionResearchProgramCompetitiveProjectGrants *Typeoforganization:AAcademia(n=14)DIndustry(n=8)MMilitary(n=11)GOthergovernment(n=1)NationalStockNumberUnmannedaerialvehicleWalterReedArmyInstituteofResearchUSEnvironmentalProtectionAgency**NavyEntomologyCenterofExcellenceUSArmyMedicalResearchUnit,KenyaUSCentersforDiseaseControlandPreventionNationalCenterforZoonotic,Vector-Borne,andEntericDiseases

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14www.cs.amedd.army.mil/references_publications.aspxexceeded$200,000peryearfor3years.Awardeesareencouragedtoseekpatentsandfindlicenseesfortheirproducts,severalofwhicharealreadynearingcommercialization.Forexample,in2005agrantwasawardedtoADAPCO(Sanford,Florida)todevelopetofenprox35foruseasmosquitoultralowvolume(ULV)adulticide.Thischemical,anonesterpyrethroidmanufacturedbytheMitsuiGroupinJapanandlicensedtoCentralLifeSciences(Schaumburg,Illinois)forUSregistrationforpublichealthapplications,isfarlesstoxictohumans,animals,andbirdsthanmostotherinsecticidescurrentlyusedformosquitocontrol.36ItisexpectedtoreceiveEPAapprovalformarketingthisyear.AlthoughtheDWFPprogramprioritizesthediscoveryanddevelopmentofagentsforuseagainstblood-feedingadultmosquitoesandbitingfliesthatwouldafflictdeployedmilitarypersonnel,someresearchgrantshavebeenawardedfordevelopmentofchemicalswithnewmodesofactionagainstmosquitodevelopmentalstagesinwater.AttheUniversityofWisconsin,Madison,Lanandcolleagues37-41hadtheideatoblocksterolcarrierproteinsthataremetabolicallyessentialforthenutritionandgrowthofmosquitolarvae.Afterscreeningtensofthousandsofcandidatecompounds,theydiscoveredseveralwiththepowertoblockmosquitosterols,effectivelyservingasgrowthinhibitors.Themostappropriatecompoundhasbeenlicensedbyacommercialcompanywhereitisbeingformulatedforapplieduse.BothphasesoftheworkhavebeensupportedbyDWFPgrants.AmongDWFPgrantsawardedtoscientificallyqualifiedmilitaryofficers,thefirstwasforadaptinganunmannedaerialvehicle,showninFigure1,tocarryapplicationequipmentfordeliveryoflarvicidalgranulesorULVadulticide.ThisprojectoriginatedwiththeDiseaseVectorEcologyandControlCenter(nowtheNavyEntomologyCenterofExcellence)attheJacksonvilleNavalAirStation,wherecapabilitiesweredemonstrated,thenadoptedbytheUSAFAerialSprayUnit*atYoungstown,Ohio.TofurtherdevelopthisapplicationtechnologywithanunmannedaerialvehicleplatformmadeintheUnitedStates,theprojecthasbeentransferredtotheApplicationTechnologyLaboratoryoftheUSDAARSattheAPMRU.ThisrelayofprogressiveresearchanddevelopmentstepshasbeenfacilitatedbyDWFPfundsandobjectivestomeetoneofthestrategicDoDgoalsoffieldingunmannedvehicles.AlsobycollaborationwiththeNavyEntomologyCenterofExcellence,aseriesofDWFPgrantshaveenabledDorendorfAdvancedTechnologies,Inc(Winnebago,Minnesota)todesignandbuildnewsprayersusingmilitaryfuelsinsteadofgasoline.Thefirstbackpacksystem,showninFigure2,operatesalmostsilentlywithcompressedairfromcylinderschargedbyadiesel-fuelledcompressorwhichalsodrivesatruck-mountedULVsprayer,theTerminator.Inadditiontothestrategicadvantagesofsilentspraying,auniqueULVnozzleisbeingcreatedforthebackpacksystem.Altogether,this Figure1.YamahaRMaxunmannedaerialvehiclefittedwithULVspraynozzles(top)andwithtwinhopper(bottom)forapplicationofgranularlarvicidetocontrolmosquitoes. *Seerelatedarticleonpage54.TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoes

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AprilJune200815THEARMYMEDICALDEPARTMENTJOURNALpurpose-built,diesel-fuelledsprayequipmentwillallowtroopstobedeployedwithbattlefield-readysprayequipmentforvectorcontrol.Fromdiverseproposalsforbetterinsectrepellencyoffabricstoprotectmilitarypersonnel,oneDWFPgrantwasawardedtoresearchersattheInstituteofEnvironmentalandHumanHealth,TexasTechUniversity,Lubbock,Texas.Thatingeniousprojectdevelopedanewtypeofpermethrin-impregnatedhollowfibercapableofbeingintegratedwithmanytextiles.Thisdurablemicrocapillarycanserveasaconvenientcarrierfiberforweavingtherepellentandinsecticidalpowersofpermethrinintoanyfabricsusedformakingclothes,curtains,tents,andotherprotectivelayers.*TwoDWFPprojectshaveemployedpyriproxyfen,themostpowerfulinsectgrowthregulator(IGR),againstdenguevectormosquitoes.InthePeruvianAmazoncommunityatIquitos,Stancil42(NavalMedicalResearchCenterDetachment,Peru)receivedagranttooptimizestrategiesforpreventingthebreedingofAedesaegyptimosquitoesincontainersofwater.Theprojectranfor3years,andinvolvedcollaborationwithPeruvianscientistsandresearchersfromtheUniversityofCaliforniaandRothamstedResearch,UnitedKingdom.Inadditiontosimplystoppingthebreedingofmosquitoesintreatedhabitats,effectivequantitiesofpyriproxyfenIGRaretransferredfromonecontainertoanotherbymosquitofemalesastheygofromsitetositelayingtheireggs,thusimpactingmorehabitatsthanweretreateddirectly.Mosquitopopulationsuppressionacrosswholesuburbsofthecityhaseffectivelypreventeddenguetransmissionwithouttheneedtosprayadulticides.Buildingonthatachievement,researchersattheArmedForcesResearchInstituteofMedicalSciences,Bangkok,43inconjunctionwithlocalmilitarypersonnelinThailand,arenowevaluatingseveraldevicestreatedwithpyriproxyfenIGRforprotectingmilitarycampsagainstAedesaegyptiandthearbovirusestransmittedbythiswidespreaddomesticmosquito(seeTable1).ThebiggestemphasisofDWFPprojectshasbeentofindwaystocombatPhlebotomussandflies(Figure3)whichareproblematicinmanypartsoftheMiddleEast.ThesesmallhairyfliestransmitLeishmaniaparasitesthatcausedisfiguringsores(Figure4)whichfesterformanymonthsandrequirelong-termmedication.Someformsoftheinfectiongototheliverandcanbefatal.MorethanathousandUSpersonnelhavecontractedleishmaniasisduringongoingOperationsEnduringFreedomandIraqiFreedom.44Unfortunately,thetypesofinsecticidespraysthatnormallycontrolmosquitoesaregenerallyineffectiveagainstsandflies.Toaddressthisthreat,DWFPgrantswerechanneled,bycompetitiveaward,viatheEntomologyDivisionattheWalterReedArmyInstituteofResearchtofacilitateintensivefieldstudiesofsandflybehaviorandcontrol.AlthoughaseriesofresearchpapersbyColeman,Burkett,andcolleagues45-47haveresulted,thesandflybitingproblemhasnotbeenresolved.Consequently,effortstounderstandhowtoimprovethedeliveryofmoreeffectiveinsecticidalspraysarebeingreemphasized.Also,Warburgandcolleagues48attheKuvinCenteroftheHadassahMedicalSchool,Jerusalem,receivedaDWFPgranttodevelopmeasurestoprotectoutpostsagainstsandflies.Theseprojectshaverevealedthatsandfliesoftenemergefromthesoilbeneathtentsandcamps.Inanefforttopreventsandfliesbreedinginrodentburrows,theGenesisCompany(Wellington,Colorado)wonanawardforproducinginsecticidalbaitsthatwouldpassthroughspecificrodentreservoirhostsofleishmaniasistopreventbreedingofsandflylarvaeintheirburrows.Thisapproachisbeingdevelopedwithotherfeed-throughtreatmentsbyMascarietal49-51atLouisiana Figure2.ThefirstbackpackULVsprayersystemdevelopedunderDWFPgrantsoperatesalmostsilentlywithcompressedairfromcylinders. Figure3.Phlebotomussandfly(PhotocourtesyofEdRowton,PhD) *Projectresultsunpublishedtodate

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16www.cs.amedd.army.mil/references_publications.aspxStateUniversityforfieldtestingagainstsandfliesinTurkey.Controloffilthfliesandhousefliesisbestachievedbygoodsanitation,butthiscannotalwaysbeensuredindeploymentsituations.OnecompetitiveDWFPawardenabledKoehler52andmilitarystudentsintheUrbanEntomologyUnitoftheDepartmentofEntomologyandNematologyattheUniversityofFlorida,Gainesville,tooptimizesomeoldcountermeasuresforflycontrol.Forexample,onestudentevaluatedpesticidesforresidualtreatmentsofvarioustypesofstringandropeonwhichfliesliketorest.Hedeterminedwhichcombinationofinsecticideandstringfiberwouldbemosteffectiveforuseagainstfliesintentedcamps.Anotherstudentcontinuesthislineofexperimentationbydevisingwaystodrapeloopsoftreatedstringoverattractanttrapstowhichfliesareluredandkilled.ThesemasterslevelgraduatestudentsweresupportedbytheUSNavysMedicalServiceCorpsInserviceProcurementProgram.53AnotherdevelopmentfromKoehlersteam,invisibleimidaclopridpaintbaitwithattractantforkillingfliesquickly,wasthefirstDWFPproducttoreceiveaNationalStockNumberfromtheArmedForcesPestManagementBoard.AstheDWFPcompetitivegrantsprogramhasgrown,awardeeshaveincludedentomologistsattheUSCentersforDiseaseControl,DivisionofVector-BorneandZoonoticDiseases,fordevelopmentofnaturalpesticidesextractedfromagriculturalwaste.Otherplantproductsthathaveinsectrepellentpropertiesareunderevaluationforinsecticidalpotencyagainstflies,mosquitoes,andsandflies,whileScharfandSong54,55areexploringlowmolecularweightcompoundsthatcouldserveasvolatilerepellentsandinsecticidesforpotentiallimitationofbitinginsectsoverawidearea.Althoughthepublicperceptionofpesticidescanbeunfavorable,thefactsarethattheuseofpesticidescanbeextremelyeffectiveagainstallsortsofpestsanddiseasevectors.Inanefforttoinvestigatethisdichotomy,oneofthemostoriginallinesofinquiryfundedbyDWFPcompetitivegrantshasallowedPetersonandcolleagues56-61atMontanaStateUniversity,Bozeman,toundertakecomparativeriskanalysesoftheimpactofpesticides.Foraseriesofmodelscenariosinvolvingvector-bornediseasessuchasmalaria,WestNilefever,andplague,theycarefullyquantifiedthelikelybenefitsofvectorcontrolbymeansofappropriateinsecticideapplications,versuspossibledisadvantagestothehealthofpeopleandenvironmentalimpact.OneparticularstudybyMacedoetal62weighedthepotentialhealthbenefitsofvectorcontrolagainsttheadverseconsequencesoflikelyexposureofdeployedmilitarypersonneltopesticidesusedonclothingandbednets,andsprayedaroundthecamp.Inallcases,therisktohumanswasfoundtobeminimalcomparedwiththehealthbenefitsofavoidingvector-bornediseases.UPGRADINGDEFENSEAGAINSTDISEASESTRANSMITTEDBYINSECTBITESWhilemanyusefulproductsfromDWFPresearcharealreadyonthewaytowardsproductionandsupplyforthepublicaswellasdeployedtroops,theexamplesdescribedabovearefarfromsufficienttocoverallourneeds.Apartfromcombatingmosquitoesandthevarioustypesoffliesthattransmitdebilitating Figure4.ExamplesofdermalleishmaniasiscontractedinIraqduringOperationIraqiFreedom.Noteinthetopphotothattheareaofthearmcoveredbytheshirtsleeveisfreeofbites,demonstratingthevalueofsimplemeasuresinthepreventionofinsectbites.(PhotoscourtesyofCOLRussellColeman,MS,USA) TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoes

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AprilJune200817THEARMYMEDICALDEPARTMENTJOURNALinfectionssuchasmalaria,leishmaniasis,dengue,andotherarboviruses,therearemanyothernoxioustypesofbitinginsects(bedbugs,fleas,lice,etc)andotherarthropods(ticks,mites,scorpions,etc)thatmeritourconcern.Withnearly5yearsofprogressintheDWFPprogram,however,ourfocusremainsonthemostdangerousflyingvectors,particularlycertainspeciesofmosquitoesandsandflies.Thatfocusisnecessaryuntilwehavegreatlyimprovedmethodsandmaterialstoprotectourforcesdeployedtoforwardsituationsinallregionsoftheworldfromthethreatsofinconspicuousinsectfoes.Thiswillallowthoseforcestomoreeffectivelydealwiththechallengespresentedbythemoreobvioushumanenemies.REFERENCES 1.AgricultureResearchServiceresearchpage.USDeptofAgriculturewebsite.Deployedwar-fighterprotection(DWFP)program.January2007.Availableat:http://www.ars.usda.gov/Research/docs.htm?docid=14013.AccessedMay1,2008.2.CoatesJB,ed-in-chief.Communicablediseases,malaria.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;1963.HoffEC,ed.PreventiveMedicineinWorldWarII;vol6.3.DickensT.Vectorcontrolasaforcemultiplier.Defense90.September/October1990:26-35.4.TechnicalGuide36,PersonalProtectiveTechniquesAgainstInsectsandOtherArthropodsofMilitaryImportance.Washington,DC:USArmedForcesPestManagementBoard.2003.Availableat:http://www.afpmb.org/coweb/guidance_targets/ppms/TG36/TG36.htm.5.DebbounM,RobertL,OBrienL,JohnsonR,BertS.Vectorcontrolandpestmanagement.ArmyMedDeptJ.2006;24:31-39.6.ServiceMW,ed.TheEncyclopediaofArthropod-transmittedInfections.Wallingford,Oxfordshire,UnitedKingdom:CABI;2001.7.MasterMemorandumofUnderstandingBetweenUnitedStatesDepartmentofDefenseandUnitedStatesDepartmentofAgricultureRelativetoCooperationwithRespecttoFood,Agriculture,PestManagement,Nutrition,RelatedHomelandSecurityRequirements,andotherResearchofMutualInterest.Washington,DC:USDeptofAgriculture&USDeptofDefense;March14,2003.Availableat:http://www.afpmb.org/pubs/misc/mastr_usda.pdf.8.SupplementtoMasterMemorandumofUnderstandingBetweenUSDepartmentofDefenseandUSDepartmentofAgriculture,RelativetoCooperationwithRespecttoFood,Agriculture,PestManagement,Nutrition,RelatedHomelandSecurityRequirements,andotherResearchofMutualInterest.Washington,DC:USDeptofAgriculture&USDeptofDefense;February5,2004.Availableat:http://www.afpmb.org/pubs/misc/MMOU-Supplement.pdf.9.KniplingEF.InsectcontrolinvestigationsoftheOrlando,Fla,laboratoryduringWorldWarII.SmithsonRepfor1948.Washington,DC:SmithsonianInstitution;1949:331-348.SmithsonianPublication3968.10.KingWV.ChemicalsevaluatedasinsecticidesandrepellentsatOrlando,FLA;AgriculturalHandbookNo.69.Washington,DC:AgriculturalResearchService,USDeptofAgriculture;1954.11.MaterialsEvaluatedasInsecticides,Repellents,andChemosterilantsatOrlandoandGainesville,FLA,1952-1964.AgriculturalHandbookNo.340.Washington,DC.AgriculturalResearchService,USDeptofAgriculture;1967.12.SullivanWN.ThecouplingofscienceandtechnologyintheearlydevelopmentoftheWorldWarIIaerosolbomb.MilMed.1971;136(2):157-158.13.McCabeET,BarthelWF,GertlerSI,HallSA.Insectrepellents,III.N,N-diethylamides.JOrgChem.1954;19:493498.14.SchreckCE,PoseyK,SmithD.Durabilityofpermethrinasapotentialclothingtreatmenttoprotectagainstblood-feedingarthropods.JEconEntomol.1978;71:397-400.15.SchreckCE,SmithN,McGovernTP.Repellencyofselectedcompoundsagainsttwospeciesofbitingmidges(Diptera:Ceratopogonidae:Culicoides).JMedEntomol.1979;16:524-527.16.SchreckCE,SnoddyEL,SpielmanA.PressurizedspraysofpermethrinorDEETonmilitaryclothingforpersonalprotectionagainstIxodesdammini(Acari:Ixodidae).JMedEntomol.1986;23:396-399.17.IR-4Projectwebsite.Availableat:http://www.ir4.rutgers.edu/index.html.18.ChauhanKR,KlunJA,DebbounM,KramerM.FeedingdeterrenteffectsofcatnipoilcomponentscomparedwithtwosyntheticamidesagainstAedesaegypti.JMedEntomol.2005;42(4):643-646.

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18www.cs.amedd.army.mil/references_publications.aspx19.NicholsZ,VogtRG.TheSNMP/CD36genefamilyinDiptera,HymenopteraandColeoptera:Drosophilamelanogaster,D.pseudoobscura,Anophelesgambiae,Aedesaegypti,Apismellifera,andTriboliumcastaneum.InsectBiochemMolBiol.2008;38:398-415.20.PridgeonJW,PereiraRM,BecnelJJ,AllanSA,ClarkGG,LinthicumKJ.SusceptibilityofAedesaegypti,CulexquinquefasciatusSay,andAnophelesquadrimaculatusSayto19pesticideswithdifferentmodesofaction.JMedEntomol.2008;45(1):82-87.21.PridgeonJW,BecnelJJ,StrickmanDA,inventors.Newmethodfordevelopingmolecularpesticides.Patentapplicationserialnumber11/716,499Docket#0122.06,March9,2007.Informationavailableat:http://www.ars.usda.gov/research/patents/patents.htm?serialnum=11716499.22.ZhaoL,PridgeonJW,BecnelJJ,ClarkGG,LinthicumKJ.Cytochromecgeneandproteinexpression:developmentalregulation,environmentalresponse,andpesticidesensitivityinAedesaegypti.JMedEntomol.2008;45:401-408.23.PridgeonJW,ZhaoL,BecnelJJ,StrickmanDA,ClarkGG,LinthicumKJ.TopicallyappliedAaeIAP1double-strandedRNAkillsfemaleadultsofAedesaegypti.JMedEntomol.2008;45:414-420.24.QuinnBP,BernierUR,GedenCJ,HogsetteJA,CarlsonDA.Analysisofextractedandvolatilecomponentsinblackstrapmolassesfeedascandidatehouseflyattractants.JChromatographA.2007;1139(2):279-284.25.KatritzkyAR,WangZ,SlavovS,TsikoliaM,DobchevD,AkhmedovNG,HallCD,BernierUR,ClarkGG,LinthicumKJ.Synthesisandbioassayofimprovedmosquitorepellentspredictedfromchemicalstructure.ProcNatlAcadSciUSA.2008;105(21):7359-7364.26.BernierUR,AllanSA,QuinnBP,KlineDL,BarnardDR,ClarkGG.VolatilecompoundsfromtheintegumentofWhiteLeghornChickens(GallusgallusdomesticusL.):candidateattractantsofornithophilicmosquitospecies.JSepSci.2008;31:1092-1099.27.CooperbandMF,AllanSA.Behavioraldefinitions,excito-repellency,andismeaningwithrespecttomosquitocontactwithtreatedsurfaces.Abstract242ofthe74thAnnualMeeting,AmericanMosquitoControlAssociation,Sparks,Nevada.2-6March2008.MountLaurel,NJ:AmericanMosquitoControlAssociation;2008:44.Available(registrationrequired)at:http://www.afpmb.org/pubs/dwfp/meetings/amca2008/224-cooperband.pdf.28.LynME,StreettD,BecnelJ.Newmosquitobiolarvicideformulationforimprovedresidualactivity.Abstract242ofthe74thAnnualMeeting,AmericanMosquitoControlAssociation,Sparks,Nevada.2-6March2008.MountLaurel,NJ:AmericanMosquitoControlAssociation;2008:47.29.CantrellCL,KlunJA,BrysonCT,KobaisyM,DukeSO.IsolationandidentificationofmosquitobitedeterrentterpenoidsfromleavesofAmerican(Callicarpaamericana)andJapanese(Callicarpajaponica)beautyberry.JAgricFoodChem.2005;53:5948-5953.30.PridgeonJW,MeepagalaKM,BecnelJJ,ClarkGG,PereiraRM,LinthicumKJ.Structure-activityrelationshipsof33piperidinesastoxicantsagainstfemaleadultsofAedesaegypti(Diptera:Culicidae).JMedEntomol.2007;44(2):263-269.31.BecnelJJ,PridgeonJW.Ahighthroughputscreeningmethodtoidentifypotentialpesticidesformosquitocontrol.JMedEntomol.Inpress.32.HoffmannWC,WalkerTW,SmithVL,MartinDE,FritzBK.Droplet-sizecharacterizationofhandheldatomizationequipmenttypicallyusedinvectorcontrol.JAmMosqControlAssoc.2007;23:315-320.33.HoffmannWC,WalkerTW,MartinDE,BarberJA,GwinnT,SmithVL,SzumlasD,LanY,FritzBK.Characterizationoftruck-mountedatomizationequipmenttypicallyusedinvectorcontrol.JAmMosqControlAssoc.2007;23:321-329.34.NachmanRJ.InvertebrateNeuropeptidesVIII.Introduction.Peptides.2008;29:149-151.35.WorldHealthOrganization.Reportofthe3rdWHOPESWorkingGroupMeeting,23-24September1999;Reviewof:Deltamethrin1%SCand25%WT;Etofenprox10%ECand10%EW.Geneva,Switzerland:WorldHealthOrganization;1999:DocumentCDS/CPE/WHOPES/99.4.36.CroftAM,BakerD,vonBerteleMJ.Anevidence-basedvectorcontrolstrategyformilitarydeployments:theBritishArmyexperience.MedTrop(Mars).2001;61:91-98.37.LanQ,WesselyV.Expressionofasterolcarrierprotein-xgeneintheyellowfevermosquito,Aedesaegypti.InsectMolBiol.2004;13:519529.38.BlitzerEJ,YazunovaI,LanQ.FunctionalanalysisofAeSCP-2usinggeneexpressionknockdownintheyellowfevermosquito,Aedesaegypti.InsectMolBiol.2005;14:301-307.TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoes

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AprilJune200819THEARMYMEDICALDEPARTMENTJOURNAL39.KimMS,WesselyV,LanQ.Identificationofmosquitosterolcarrierprotein-2inhibitors.JLipidRes.2005;46:650-657.40.VyazunovaI,WessleyV,KimM,LanQ.Identificationoftwosterolcarrierprotein-2likegenesintheyellowfevermosquito,Aedesaegypti.InsectMolBiol.2007;16:305314.41.LarsonRT,WesselyV,JiangZ,LanQ.Larvicidalactivityofsterolcarrierprotein-2inhibitorinfourspeciesofmosquitoes.JMedEntomol.2008;45(3):439-444.42.SihuinchaM,Zamora-PereaE,Orellana-RiosW,StancilJD,Lopez-SifuentesV,Vidal-OrC,DevineGJ.PotentialuseofpyriproxyfenforcontrolofAedesaegypti(Diptera:Culicidae)inIquitos,Peru.JMedEntomol.2005;42(4):620-630.43.ArmedForcesResearchInstituteofMedicalScienceswebsite.Availableat:http://www.afrims.org.AccessedMay1,2008.44.AronsonNE.LeishmaniasisinrelationtoserviceinIraq/Afghanistan,U.S.armedforces,2001-2006.MedSurveillMonRep.2007;14(1):2-5.45.ColemanRE,BurkettDA,PutnamJL,etal.ImpactofphlebotominesandfliesonUSmilitaryoperationsatTallilAirBase,Iraq:1.background,militarysituation,anddevelopmentofaleishmaniasiscontrolprogram.JMedEntomol.2006;43(4):647-662.46.ColemanRE,BurkettDA,SherwoodV,etal.ImpactofphlebotominesandfliesonUSmilitaryoperationsatTallilAirBase,Iraq:2.temporalandgeographicdistributionofsandflies.JMedEntomol.2007;44(1):29-41.47.BurkettDA,KnightR,DennettJA,SherwoodV,RowtonE,ColemanRE.ImpactofphlebotominesandfliesonUSmilitaryoperationsatTallilAirBase,Iraq:3.evaluationofsurveillancedevicesforthecollectionofadultsandflies.JMedEntomol.2007;44(2):381-384.48.JaffeCL,BanethG,AbdeenZA,SchleinY,WarburgA.LeishmaniasisinIsraelandthePalestinianAuthority.TrendsParasitol.2004;20:328-332.49.MascariTM,MitchellMA,RowtonED,FoilLD.Evaluationofnovaluronasafeed-throughinsecticideforcontrolofimmaturesandflies(Diptera:Psychodidae).JMedEntomol.2007;44(4):714-717.50.MascariTM,MitchellMA,RowtonED,FoilLD.Laboratoryevaluationofdiflubenzuronasafeed-throughforcontrolofimmaturesandflies(Diptera:Psychodidae).JMedEntomol.2007;44(2):171-174.51.MascariTM,MitchellMA,RowtonED,FoilLD.Ivermectinasarodentfeed-throughinsecticideforcontrolofimmaturesandflies(Diptera:Psychodidae).JAmMosqControlAssoc.2008;24(2):323-326.52.KoehlerP.DWFPflycontrolresearch.Paperpresentedat:2007DoDPestManagementWorkshop;February12-16,2007;JacksonvilleNavalAirStation,Florida.Availableat:http://www.afpmb.org/meetings/TriService2007/Presentations/Wednesday/BOQAfternoon/Koehler.ppt.53.OPNAVInstruction1420.1A;EnlistedtoOfficerCommissioningProgramsApplicationAdministrativeManual.Washington,DC:OfficeoftheChiefofNavalOperations,USDeptoftheNavy;May2,2003:chap6.54.ScharfME,NguyenSN,SongC.EvaluationofvolatilelowmolecularweightinsecticidesusingDrosophilamelanogasterasamodel.PestManagSci.2006;62:655-663.55.NguyenSN,SongC,ScharfME.Toxicity,synergism,andneurologicaleffectsofnovelvolatileinsecticidesininsecticide-susceptibleand-resistantDrosophilastrains.JEconEntomol.2007;100:534-544.56.PetersonRK,MacedoPA,DavisRS.Ahuman-healthriskassessmentforWestNilevirusandinsecticidesusedinmosquitomanagement.EnvironHealthPerspect.2006;114(3):366-372.57.DavisRS,PetersonRK,MacedoPA.Anecologicalriskassessmentforinsecticidesusedinadultmosquitomanagement.IntegrEnvironAssessManag.2007;3:373-382.58.AntwiF,ShamaLM,PetersonRKD.RiskassessmentsfortheinsectrepellentsDEETandpicaridin.RegulToxicolPharmacol.2008;51(1):31-36.59.SchleierJJ,ShamaLM,DavisRS,MacedoPA,PetersonRKD.Equineriskassessmentforinsecticidesusedinadultmosquitomanagement.HumEcolRiskAssess.2008;14:392-407.60.SchleierJJ,PetersonRKD,MacedoPA,BrownDA.Environmentalconcentrations,fate,andriskassessmentofpyrethrinsandpiperonylbutoxideafteraerialultra-low-volumeapplicationsforadultmosquitomanagement.EnvironToxicolChem.2008;27:1063-1068.

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20www.cs.amedd.army.mil/references_publications.aspx61.SchleierJJ,MacedoPA,DavisRS,ShamaLM,PetersonRKD.Atwo-dimensionalprobabilisticacutehuman-healthriskassessmentofinsecticideexposureafteradultmosquitomanagement.StochEnvironResRiskAssess.2008;22,doi:10.1007/s00477-008-0227-5.62.MacedoPA,PetersonRK,DavisRS.Riskassessmentsforexposureofdeployedmilitarypersonneltoinsecticidesandpersonalprotectivemeasuresusedfordisease-vectormanagement.JToxicolEnvironHealth.2007;70(20):1758-1771.TheDeployedWarfighterProtectionResearchProgram:FindingNewMethodstoVanquishOldFoesAUTHORS CAPTCopeistheResearchLiaisonOfficeroftheArmedForcesPestManagementBoard,Washington,DC.COL(Ret)StrickmanistheNationalProgramLeader,Program104:Veterinary,Medical,andUrbanEntomologyattheUSDeptofAgriculture,AgriculturalResearchService,Beltsville,Maryland.DrWhiteisTechnicalConsultantfortheDeployedWarfighterProtectionResearchProgram,basedattheMosquitoandFlyResearchUnit,CenterforMedical,Agricultural,andVeterinaryEntomology,USDAAgriculturalResearchService,Gainesville,Florida. COLDUNEMNJOINSTHEAMEDDJOURNALEDITORIALREVIEWBOARDTheAMEDDJournalwelcomesCOLKathleenN.Dunemn,AN,USA,asamemberoftheEditorialReviewBoard.COLDunemnisChief,DepartmentofNursingScience,AcademyofHealthSciences,AMEDDCenterandSchool,FortSamHouston,Texas,andtheNursingEducation/EnlistedTrainingConsultanttotheOfficeofTheSurgeonGeneral.COLDunemnjoinstheboardreplacingCOLPatriciaPatrician,AN,USA.COLPatricianhasbeenamemberoftheBoardsinceOctober,2004.WethankCOLPatricianforherdedicationtothehighstandardsandprofessionalqualityofthispublication,andheryearsofserviceandsupporttoourmission.TheEditors

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AprilJune200821TheVectorSurveillanceAnalyticSystem(VSAS)isaportable,field-durable,field-sustainable,real-time,arthropod-borneagentdetectionplatformusedtosupportdiseasesurveillanceoperationsatfarforwardlocations.TheVSASwasoriginallydevelopedtoestablishaDoDdeployablemethodologyfordenguevirusdetection,butfocusonsystemcapabilitywasredirectedtoLeishmaniadetectionanddeployedinAugust2003tosupporttheLeishmaniasisControlProgram(LCP)ofthe520thTheaterArmyMedicalLaboratory,TallilAirBase(AB),Iraq.1ThemobilityoftheVSASalloweddirectsupporttoUSArmyPreventiveMedicineandUSAirForcePublicHealthLeishmaniasurveillanceoperationsthroughouttheLCPareaofresponsibility.ForcehealthprotectionsupportwasprovidedatCampVictory;BaghdadInternationalAirportAB;BaladAB;andKirkukAB,Iraq;andKabul,Afghanistan,fromFebruarytoOctoberof2004.TheVSASoperatesasastandalonefieldsurveillanceactivityorasanextensionofotherdeployableassets,suchastheUSArmyAreaMedicalLaboratoryortheAirForceBiologicalAugmentationTeam.ThefieldutilityoftheVSASisclearlyprovenindiverseoperationalapplicationsandenvironmentalconditions;LeishmaniasurveillanceSouthwestAsia,2denguesurveillanceatJointTaskForceBravo,Honduras,3,4andwiththeArmedForcesResearchInstituteofMedicalSciences,Bangkok,Thailand.5IthasalsobeenadaptedforuseintheArcticbyNASA*inthedevelopmentofgenomics-basedidentificationmethodologiesfortheHaughton-MarsProjectonDevonIslandintheTerritoryofNunavut,Canada.TheVSASaddressesarequirementestablishedbytheJointProgramExecutiveOffice(JPEO)forChemicalandBiologicalDefenseforthedevelopmentofdeployableidentificationtechnologiesfordiseaseagentsofoperationalsignificance.6TheJPEOhasdesignatedLeishmaniaanddenguevirusasthreatagents(Block1,Tier2).Toaddressthatthreat,testingisunderwaytoincrementallyestablishVSAStechnologiesassubcomponentsoftheJointBiologicalAgentIdentificationandDiagnosticSystem(JBAIDS),aJPEO/DoDacceptedanalyticsystem.TheVSASiscomposedof:1.Thermally-stable,hydrolyticenzymeresistant,freeze-dried,dual-fluorogenic,polymerasechainreaction(PCR)andreversetranscription-PCR(RT-PCR)assaysandpositivecontroltemplate,genomicDNAandArmored-RNA(Asuragen,Incorporated,Austin,Texas).7,82.Preformattedsamplestabilizationandprocessingmaterials.3.Two-mantransportable,field-durable,real-timePCRinstrumentation:theRuggedizedAdvancedPathogenIdentificationDevice(RAPID)(IdahoTechnologyIncorporated[ITI],SaltLakeCity,Utah).Assayprimerandprobeoligonucleotidesaredesigneddenovo,andfreeze-driedPCRreagentsaremanufacturedbyITI.2,3AssaysarepreparedusinganITIproprietaryformulationthatisformattedtostandardizedPCRandRT-PCRthermalcyclingprotocols.TheITIvectorsurveillancereagentkitispreformattedwithcolorcodingtosimplifypreparation.Freeze-driedassaysonlyrequirehydrationandadditionofsampletemplatepriortoanalysis.Thethermal-stablepropertyoftheassayseliminatetheSupportofFar-ForwardDiseaseSurveillanceOperationswithDeployable,Real-TimeVector-BorneDiseaseAgentAnalyticCapabilityColJamesA.Swaby,BSC,USAFJamesC.McAvin *NationalAeronauticsandSpaceAdministrationInformationontheresearchprojectavailableat:http://www.marsonearth.org/

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22www.cs.amedd.army.mil/references_publications.aspxneedfora-20CcoldchainthatistypicallyrequiredforPCRreagents,thusvastlyenhancingthemobilityofthesystem.Italsoeliminatescoldstorageandresupplyrequirementsthatareunacceptableunderfar-forwarddeployedconditions.Arthropodnucleicacidextractsarepreparedwithacommerciallyavailable,off-the-shelf,thermallystable,preformatted,guanidiniumthiocyanatebasedtotalnucleicacid(DNAandRNA)purificationkit,QIAampViralRNAMiniKit(QIAGEN,27220TurnberryLane,Valencia,California91355).ExtractispreparedfollowingthemanufacturersspinprotocolwiththeexceptionthatthecarrierRNAstepisnotimplemented,thuseliminatingtheneedfora4Ccoldchain.Also,centrifugationstepsareadaptedtotheRAPIDminicentrifuge,eliminatingtheneedforatabletopcentrifuge.Thiskithasbeenadoptedbecauseofitsfield-worthinessanditscapabilitytoextracttotalnucleicacidinastandardized,singleprotocolwhichisapplicabletoorganismsharboringeitherRNAorDNAgenomes.Twootheradvantagesofthekitarethelysisbuffer,AnschlagpufferVirusLysis(AVL),whichhasbeenshowntoinactivateinfectiousagents,9thusprovidinganadditionallevelofsafetywhenprocessingsamples,andthegenomicRNAtemplate,whichhasbeenshowntoremainstableinAVLatambienttemperatures(25Cto37C)fordaystoweeks.Thekitefficientlypurifiesnucleicacidfromdiversematrices,toincludemammalianbodyfluidsandtissuesandarthropodhomogenate.TheRAPIDPCRthermocycler,isareal-timefluori-meterwithaclosedcapillarydesignand32-samplecapacity.10,11ThethermocyclerisoperatedbyalaptopcomputerwithprogrammablePCRcyclingconditions.Datamanagementisautomated.TheRAPIDminicentrifugeisusedforsamplepreparationandcapillaryloading.TheRAPIDthermocycleristhecommercializedversionoftheJBAIDSthermocycler.Sincethetechnologiesofthesethermocyclersareessentiallyidentical,assayscanbereadilytransitionedfromoneinstrumenttotheother.TheVSAS,includingseveralhundredassaysandsampleprocessingmaterials,aretransportedin2hardened,waterproofcases(6349.235.2cm).TheVSASisroutinelytransportedaspersonalequipmentonmilitaryhelicoptersorfixed-wingaircraft,ortransportedoncommercialairlinesasbaggage.Groundtransportationisbylightvehicleorcarriedmanually.ThesmallfootprintoftheVSASallowsconfigurationonatrucktailgatewiththesystempoweredbya110Vor220Vsource,usuallyanelectricgenerator,or,ifnecessary,the12Vbatteryofavehiclewiththeenginerunning.Theefficiencyofpreformattedreagentandsamplepreparationkits,alongwiththeclosedcapillarydesignoftheRAPID,permitsampleprocessingandmastermixpreparationtobeconductedwithoutabiologicalcontainmenthoodorspatialseparation.However,inordertotailorprotectivemeasurestothesurveillancerequirements,appropriateoperatorpersonnelprotectiveequipmentmustbeprovidedandpersonnelmadeawareofwhichvector(s)willberecovered.Systemconfigurationrequiresabout10minutes,andsampleprocessingandanalysislessthan2hours.TheVSASprovidesdeployableanalyticcapabilityforreal-timevector-bornediseaseriskassessment.Thisisparamountinaffectingtime-criticalandfocuseddiseasepreventionandcontrolmeasures.Thisisespeciallyrelevanttoleishmaniasisanddenguefeverbecause,intheabsenceofavaccineorprophylacticdrug,theonlymeansofprotectingdeployedmilitarypersonnelisthepreventionofbitesbyinfectedarthropods.Preventionandcontroloftransmissionismosteffectivelyachievedthroughheightenedawarenessoftheneedforpersonalprotectivemeasures,andbyreductioninvectorpopulations.Focusedapplicationofinsecticidesandeliminationofbreedinghabitatinareaswheretheriskisgreatest TheRuggedizedAdvancedPathogenIdentificationDevice.SupportofFar-ForwardDiseaseSurveillanceOperationswithDeployable,Real-TimeVector-BorneDiseaseAgentAnalyticCapability

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AprilJune200823THEARMYMEDICALDEPARTMENTJOURNALwhereinfectedvectorsandbreedingpopulationsarefoundarethemosteffectiveusesofvectorcontrolresourcestoreducetransmission.1,2TheArmedForcesPestManagementBoard(AFPMB)hasapprovedLeishmaniagenus(LEIS)andvisceralgenotype(LVL)PCRassaysasDoDacceptedmethodologiesforLeishmaniavectorsurveillance.TheVSASdengueRT-PCRassay(DU-JCM)wassubmittedtoAFPMBinFebruary2008.TheLEIS,LVL,andDU-JCMassayswillbesubmittedconcurrentlytotheJPEOforapprovalascandidatesforclearancebytheUSFoodandDrugAdministrationontheJBAIDS.Additionalassaysofoperationalsignificanceareindevelopment.TheVSASisajointUSAirForce,Army,andNavyproductdevelopedthroughaCooperativeResearchandDevelopmentAgreementwithITI,theJPEOprimarycontractor. ACKNOWLEDGEMENTTheauthorsthankMAJJasonRichardson,MS,USA,forhiscommentsandsuggestionsinreviewingthisarticle.TheVSASdevelopmentwasfundedinpartbytheUSAirForceProtectionBattleLab,LacklandAirForceBase,SanAntonio,Texas,andtheDirectorateofModernizationintheOfficeoftheAirForceSurgeonGeneral,FallsChurch,Virginia. TheVectorSurveillanceAnalyticSystemoperatinginthefieldenvironmentinThailandduringAugust2007.

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24www.cs.amedd.army.mil/references_publications.aspxREFERENCES1.ColemanRE,BurkettDA,PutnamJL,etal.ImpactofPhlebotominesandfliesonUSmilitaryoperationsatTallilAirBase,Iraq:background,militarysituation,anddevelopmentofaLeishmaniasisControlProgram.JMedEntomol.2006;43:647-662.2.McAvinJC,ColemanRE,HochbergLP,etal.DetectionofLeishmaniaparasitesandvisceralleishmaniasisgenotypeidentificationinsandfliesbyfield-deployable,real-timepolymerasechainreaction.JMedEntomol.Inpress.3.McAvinJC,EscamillaEM,BlowJA,etal.RapididentificationofdenguevirusbyRT-PCRusingfield-deployableinstrumentation.MilMed.2005;170(12):1053-1059.4.McAvinJC,BowlesDE,SwabyJA,etal.IdentificationofAedesaegyptianditsrespectivelifestagesbyreal-timePCR.MilMed.2005;170(12):1060-1065.5.McAvinJC,PowersMD,BlowJA,PutmanJL,HuffWB,SwabyJA.Deployable,field-sustainableRT-PCRassaysforrapidscreeningandserotypeidentificationofdenguevirusinmosquitoes.MilMed.2007;172:329-334.6.NiemeyerDM,WilsonS,etal.Enhancedlaboratorycapabilities:thejointbiologicalagentidentificationanddiagnosticsystem.SocietyScope[SocietyofArmedForcesMedicalLaboratoryScientistsserialonline].2003;6(3).Availableat:http://www.safmls.org/Scopes/Scope%20-%202003%20Fall.pdf.7.PasloskeBL,WalkerpeachCR,ObermoellerRD,WinklerM,DuBoisDB.ArmoredRNAtechnologyforproductionofribonucleaseresistantviralRNAcontrolsandstandards.JClinMicro.1998;36:3590-3594.8.WalkerpeachCR.,WinklerM,DuBoisDB,PasloskeBL.Ribonuclease-resistantRNAcontrols(armoredRNA)forreversetranscription-PCR,branchedDNA,andgenotypingassaysforhepatitisCvirus.ClinChem.1999;45:2079-2085.9.BlowJA,DohmDJ,NegleyDL,MoresCN.Virusinactivationbynucleicacidextractionreagents.JVirolMeth.2004;119:195-198.10.WittwerCT,RirieKM,AndreRV,DavidDA,GundryRA,BalisUJ.Thelightcycler:amicrovolumemultisamplefluorimeterwithrapidtemperaturecontrol.Bioechniques.1997;22:176-181.11.WittwerCT,HerrmannMG,MossAA,RasmussenRP.ContinuousfluorescencemonitoringofrapidcycleDNAamplification.Biotechniques.1997;22:130-138.AUTHORS ColSwabyisChief,59thClinicalResearchTrainingDivision,59thMedicalWing,andPrincipleInvestigator,Vector-borneDiseaseSurveillance,59thMedicalWing/SGR,LacklandAirForceBase,Texas.HeisalsoAssociateBiomedicalSciencesCorpsChiefforMedicalEntomology,andConsultanttotheUSAFSurgeonGeneralforEntomology.JamesMcAvinisaMolecularBiologistwiththe59thClinicalResearchTrainingDivision,59thMedicalWing,LacklandAirForceBase,Texas.SupportofFar-ForwardDiseaseSurveillanceOperationswithDeployable,Real-TimeVector-BorneDiseaseAgentAnalyticCapability

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AprilJune200825BACKGROUNDWhatkindofwardoyouprepareforwhenyoucannotprepareforthemall?AndrewKrepinevichposesthequestioninhisanalysisoftheUSArmybefore,during,andafteracounterinsurgencyinVietnam.1ThequestionhasresurfacedastheArmyagainfindsitselfoperatinginacounterinsurgencyinIraq.HastheArmyasaninstitutionlearnedandimplementedchangebasedonexperiencesinthePhilippinesduringtheearly20thcentury,orVietnam,Lebanon,andElSalvadorinthelatterpartofthesamecentury?ArewetrainedandequippedtocontributetowardanoverarchingUSgovernmentstrategyaddressingunderlyingfactorsofaninsurgency?Althoughthebroaderquestionshavebeendebatedandrecommendationspublished,theroleofpreventivemedicine(PM)insupportofcounterinsurgencyoperationshasnot.Counterinsurgencyis,bydefinition,Thosemilitary,paramilitary,political,economic,psychological,andcivicactionstakenbyagovernmenttodefeataninsurgency.2TherecentlypublishedArmyFieldManual3-24:Counterinsurgency3emphasizespolitical,social,andeconomicprogramsasmorevaluablethankineticforceinaddressingtherootcauseofaninsurgency.Intheabsenceoflegitimategovernmentsprovidingforthepopulation,insurgentsdeliveressentialservicessuchaswater,electricity,sanitation,andmedicalcare.HezbollahexemplifiesthischaracterizationinthecareandservicestheyprovidefortheLebanesepopulationinexchangeforindividualstofilltheirmilitiaranks.ThispatternreplicateditselfinthestreetsofBaghdad,asobservedbythenMGPeterChiarelli.4Hefoundanti-coalitionandantigovernmentreligiousrhetoricoriginatedfromthoseareasofBaghdadcharacterizedbylowelectricaldistribution,sewagerunningrawthroughthestreets,littletonopotablewaterdistribution,andnosolidwastepickup.adirectcorrelationexistedbetweentheleveloflocalinfrastructurestatus,unemploymentfigures,andattacksonUSSoldiers.MGChiarellistudiedtheseunderlyingfactorsandachievedsuccessbyfocusingreconstructionandemploymenteffortsonsewage,water,electricity,andtrashremovalwhathecalledSWET.Threeofthese4servicesmakeupcorecompetenciesofArmyPMpersonnel.IsPMcurrentlybeingleveragedinIraq,Afghanistan,andtheHornofAfricatocontributetowardtheoverallstrategiceffort?Thatisdebatable.Aretheyformallytrainedincounterinsurgenciesanddoctrinallyestablishedtomeetthedemand?Notreally.APPLICATIONOFCURRENTDOCTRINEDoctrineforLevelIIIPMdetachmentsisdrivenbymultipleDepartmentofDefense(DoD)DirectivesandInstructions,ArmyRegulations,DepartmentoftheLevelIIIPreventiveMedicineinaCounterinsurgencyEnvironmentMAJDerekJ.Licina,MS,USA ABSTRACTAstheDepartmentofDefensemovesforwardtosecureBaghdad,militaryforcesarebeingstrategicallydispersedinveryaustereenvironments.Theseforcesliveandworkside-by-sidewiththeirIraqicounterpartsinanefforttoclear,hold,andreconstructthecityblockbyblock,andfurtherseparatetheinsurgentsfromthegeneralpopulation.LevelIIpreventivemedicine(PM)personneldirectlysupporttheseforcesandkeeptheminthefightbyreducingacuteillnessanddiseaseandnonbattleinjuries.LevelIIIPMisperformingthetraditionalPMmissionofreducingbothacuteandchronicillnesswhileconductingDeploymentOccupationalEnvironmentalHealthSurveillanceandsupportingLevelIIPM.However,thedoctrinalbasisofLevelIIIallocationandprioritiesofcorecompetencieshaveshifted.Arewemeetingtheneed?ThisarticleattemptstoanswerthequestionbasedonexperienceasaLevelIIIPMdetachmentcommanderinBaghdad,andproviderecommendationsforchangeacrossthespectrumoftheArmysstructureofdoctrine,organizations,training,materiel,leadership,education,personnel,andfacilities.

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26www.cs.amedd.army.mil/references_publications.aspxArmyPamphlets,andmyriadFieldManuals.ThemostrobustdescriptionofdutiesandresponsibilitiesisfoundinFieldManual4.02-17,PreventiveMedicineServices,5whichwaslastupdatedinAugust2000.IthighlightsLevelIIIsupportintheareasofmedicalthreatanalysis,healthhazardassessment,diseaseandnonbattleinjury(DNBI)surveillance,healthphysicssurveys,disease-vectoridentification,environmentalhealthassessments,andfieldsanitationteamtraining,amongotheroperationalcapabilities.Theseareasarerelevantinbothpermissiveandnonpermissiveenvironments,thoughtheiroverallprioritymayshift.PMservicesinstability,support,andcivil-militaryoperationsarediscussedinFieldManual4.02-17andmoreaccuratelydescribewhatcontributionsPMcanmakeinacounterinsurgency.Duringthe2007surgeinoperationsinBaghdad,the61stMedicalDetachmentprovidedLevelIIIsupporttothemultinationaldivisionsinBaghdadandcentralIraqwhichwereengulfedinacounterinsurgency.Over70,000US,Coalition,contractor,andthirdcountrynationalssupportedoperationsinthisnefariousbattlespace.Doctrinallyestablishedtosupport17,000personnel,the61stMedicalDetachmentinrealityperformedthemissionof4detachments.Theyprovidedsupportinanareaover80,000km2,including20forwardoperationbases(FOBs),70jointsecuritystations(JSSs)andcombatoutposts(COPs),andtheVictoryBaseComplex,whichisequivalenttoamidsizemunicipalityintheUnitedStates.DoctrinestatesthatLevelIIIPMis100%mobile,however,duringthecounterinsurgencyinIraq,thishasonlybeentrueontheFOBstowhichtheywereassigned.MovingbetweenFOBsrequiresexternalsupportsuchasuparmored*vehicles,helicopters,andstalwartsecurity.Thecriteriaforthisdoctrinalbasisofallocationshouldbefurtherexplored.NewcriteriasuchasthenumberofLevelIIPMassetssupported,ortypeofconflict(counterinsurgency,peacekeeping,ordisasterresponse/humanitarianassistance)couldbeaddedandweightedtodetermineoperationalneedsontheground.DuringtheOperationIraqiFreedom(OIF)06-08rotation,the61stMedicalDetachmentexecutedamajorityofthesedoctrinaltasks.Priortodeployment,amedicalthreatprofilebasedonhazardsintheareaofoperationwasdeveloped.NotconsideredduringthisanalysiswerediseasesthatcouldbebroughtintotheaterbyCoalitionforcesandcontractpartnerswhomaynotrequirestringentpredeploymenthealthscreening.RoundworminfectionsandbedbuginfestationsamongemployedthirdcountrynationalsprovidingservicestoCoalitionpersonnelwerenotuncommon.Healthhazardassessmentswereconductedtocharacterizeexposuretotheomnipresentdust,smokefromburningsolidwaste,anddiversechemicals.Asthewarspiraledintoacounterinsurgency,CoalitionforcesmovedintourbanenvironmentsinandaroundBaghdadtoestablishJSSsandCOPs.Theselocationswerebasedamongexistinginfrastructurewhererunningwaterwasintermittentandsolidwastedisposalnonexistent.ThisposedincreasedrisktoCoalitionpersonnelperformingpersonalhygieneusinglocalwater,defecatinginimprovisedcontainers,andlivingnexttosolidwasteburnpitsusedtoeliminatetrashanddecreasetherodentandvectorpopulations.LevelIIPMprovideddirectsupporttotheseausteresiteswhichrapidlygrewinnumber.OccupationalEnvironmentalHealthSurveillanceattheselocationswaslimitedduetotime,thedailyenemythreat,andcompetingacutehealthpriorities.Doctrinally,surveillancefordiseaseandnonbattleinjury(DNBI)istheresponsibilityofLevelIIIPM.Unfortunately,orfortunatelydependinguponperspective,the61stMedicalDetachmentdidnotmonitorDNBIs.AnexcellentrapportwasestablishedwiththeTheaterMedicalCommandPMphysicianwhomonitoredDNBIsandnotifiedthe61stMedicalDetachmentofpatternsortrendswithintheirareaofoperation.ThisallowedLevelIIIPMtofocusenergyonpreventionwhileknowinganyspikeinillnesswouldbeidentifiedandcollaborativelyaddressedinatimelymanner.Unfortunately,thismethodbuildsdependencyandreducesrecognitionandassessmentskillsthatcouldbeemployedinacounterinsurgencyenvironmentwhenworkingwithhostnationsecurityforcesorthelocalcivilianpopulation.MEETINGTHENEEDINACOUNTERINSURGENCYThesearejustafewexamplesofhowLevelIIIPMaddresseddoctrinaltasksduringacounterinsurgency. *Militaryvehicleswhichhavebeenreinforcedwithadditionalarmortocountertheaffectsofroadsideandburiedbombs,andimprovedpenetratingdirectfiremunitions.LevelIIIPreventiveMedicineinaCounterinsurgencyEnvironment

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AprilJune200827THEARMYMEDICALDEPARTMENTJOURNALThereareotherexampleswheretheArmycouldlearnfromLevelIIIsuccessesandfailurestodrivechange.TheArmyusesdoctrine,organizations,training,materiel,leadership,education,personnel,andfacilities(DOTMLPF)asaproblem-solvingconstructforassessingcapabilitiesandmanagingchange.6RecentexperienceinIraqandareflectiononpreviouscounterinsurgencyoperationsprovidejustificationtostimulatechangewithinthePMfieldusingtheDOTMLPFconstruct.DoctrineTheglobalshiftofpopulationstowardurbanareasandtheinabilityofgovernmentstoprovidebasicservicesfuelsinsurgenteffortstoexploitthedisenfranchised.4Counterinsurgenciesarebuilttoaddressthesegroupsandunderlyingfactors.Suchoperationsarealong,slowprocessthatrequirestheintegrationofallelementsofnationalpowertoaccomplishthetasksofcreatingandsupportinglegitimatehostgovernmentsthatcanthendefeattheinsurgency.7TheVietCongunderstoodthepowerofPMandemployedsanitationextensivelyintheircivicactionandpropagandaefforts.TheyusedsloganssuchasPreventionofDiseaseisPatriotismandPreventionofDiseaseisFightingtheAmericans.8DrRichardCarmona,theUSSurgeonGeneral,reflectedonhistimeasaSpecialForcesmedicduringthewarinVietnam:PMisprobablythemostimportantthingIlearnednotonlywasIresponsibleforthehealthcareofmyteam,butforanentirevillageaswell!9BothsidesrealizedinteractionsbetweenSoldiersandindigenouspopulationsprovidedopportunitiestomakepositiveimpressionsandobtainsupportfromthepopulation.10Inthecurrentsituation,theshortageofinternationalandnongovernmentalorganizationsinIraqmeansthatmilitaryforcespossesstheonlyreadilyavailablecapabilitytosupporttheneedsofthepopulation.Currentcivil-militaryoperations(CMO)doctrinementionsbuildinghostnationcapacityandlocalsufficiencyintheareasofhealtheducation,watersupply,andwastedisposal.5TheseareasareripeforinterventionbyLevelIIIPMworkingthrough,by,andwithhostnationcounterpartstofillthevoidinessentialservices,providelegitimacytothegovernment,andstimulatetheeconomythroughjobcreation.Understandingthesecapabilities,the61stMedicalDetachmentandtheMultinationalCorps-IraqForceHealthProtectionOfficerreachedouttotheCorpsCMOstaff.DiscussionsacknowledgedthatProvincialReconstructionTeams(PRTs)andCivilAffairs(CA)unitshavenoorganicPMequipmentandshouldcoordinatewithPMdetachmentsforsupport.5,11Offersweremadetohavethe61stMedicalDetachmentadvise,coordinate,andevaluatepublichealthresourceswithintheirrespectiveareasofoperationtoadvancehostnationservicesprovidedtothepopulation.12Conceptualagreementwasachievedandlaudatorycommentsmade,however,strategicsupportwasnotprovided.Theyrequestedthatthesubjectberevisitedinthefuture,butshorttermtacticalneedsdictatedthatLevelIIIPMpursueotheravenuesofsupport.Asofthiswriting,the61stMedicalDetachmentisworkingwiththe1stCalvaryDivisionG9CMOstafftoaddressthesignificantvoidinpublichealthandsanitation.Progressisslow.TheomnipresentchallengesofPMunitsengagingPRTandCApersonnelmayberootedinCAandPMindoctrinationcourses,whichisexploredlaterinthisarticle.OrganizationsThehistoryofPMeffortshighlightdifferent,yetsynergisticcapabilitiesbetweenveterinaryandpreventivemedicinepersonnel,whichcouldbeemployedinIraqandfuturecounterinsurgencies.Forexample,whenmillionsofPakistanisweredisplacedfromtheirhomes,amajorreliefeffortwasmountedbyPMphysicians,aPMcompany,and42enlistedper-sonnel.13Thiswasnotthe2005earthquakedisasterresponseinPakistan,ratherthereliefeffortfollowingthefloodingoftheBrahmaputraRiverin1954.In1963,ateamof4physicians,3sanitaryengineers,anentomologist,and8PMtechniciansadministered41,000dosesoftyphoidfevervaccine,deloused9,000people,andtreated75wellsfollowingintensefloodinginMorocco.14ArmyVeterinaryCorpsofficersactivelyparticipatedintheMedicalCivicActionprograminVietnamwheretheypreventedzoonoticdiseasesandprovidedtreatmentandcaretodomesticanimals.15Unfortunately,currentorganizationalstructurewithinveterinaryandPMcommunitiesdoesnotleveragecapabilities;rather,thestructurefosterscompetitioninaccomplishingsimilargoals.Inanefforttoreduceperceivedandactualfoodandwaterinspectionoverlap,seriousconsiderationshouldbegiventomergingtheVeterinaryFoodInspectionSpecialist(militaryoccupationalspecialty(MOS)

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28www.cs.amedd.army.mil/references_publications.aspx68R)andPMSpecialist(MOS68S).Titlethenewspecialty68RS,PublicHealthSpecialistandestablishdoctrineandtrainingtomeetthefutureneed.Expertsinbothfieldshavevacillatedoverthisconceptforyears.Unfortunately,todatetherehasbeenlittlerecognitionoftheimmediateandfutureapplicationofcreatingamoredynamicSoldiertomeettacticalandoperationalneedsincounterinsurgencymissions.Buildinguponthepublichealthsynergyofthenew68RSMOS,theorganizationalstructureofLevelIIIPMcouldbechangedtoenhancetheefficiencyandeffectivenessoftheirefforts.ThecurrentModifiedTableofOrganizationandEquipment*(MTOE)assigns13personneltothedetachmentasshowninFigure1.IncreasingtheMTOEto14assignedwith3additionaldesignatedpersonneltobeaddedduringdeployment(similartothefunctionoftheProfessionalOfficerFillerInformationSystem16)asshowninFigure2,couldgreatlyenhancethedetachmentscapabilitiesinacounterinsurgency.VeterinarymedicalcareisprovidedtoCoalitionmilitaryandcontractworkingdogsinIraq,however,minimalengagementwithindigenousanimalpopulationsisoccurring.Team4ofthisconceptualmedicaldetachmentcouldaddresshostnationfoodproduction,provideanimalhusbandrytraining,andsupportvaccinationandzoonoticdiseasesurveillanceprograms.Onecanarguethatthesemissionsarepartofexistingveterinarydoctrine,buttheyarenotbeingperformedinIraq.17ColocatingPMandveterinarymedicineassetsonthesameforwardoperatingbasemayfacilitatecoordination,butassigningbothspecial-tiestoaPMdetachmentwouldsynchronizethesecapabilitiestowardacommongoal.Conversely,thisconceptcouldbeappliedtoaveterinarydetachmentbyaddinganEnvironmentalScience/EngineerOfficer(MOS72D/E)andPublicHealthSpecialists(MOS68RS)totheirMTOE.Additionally,theMedicalLaboratorySpecialist(MOS68K10)wouldbringacomprehensivelaboratorycapabilityfortheanalysisoffood,water,tissue,blood,andbodyfluid.Basedontheexperienceswithlegionella,MethicillinResistantStaphylococcusAureus,tuberculosis,Q-fever,andsuspectedcasesofleishmaniasis,histoplasmosis,salmonella,E.Coli,andotherillnessesduringtheOIF06-08rotation,theMedicalLaboratorySpecialistmustbequalifiedtotestforsomeoftheseandotherinfectiousagentsfoundinaustereenvironments.TheMedicalLogistics *Definesthestructureandequipmentofamilitaryorganiza-tionorunit. HEADQUARTERSCommander(Major,MOS72D/B*)ExecutiveOfficer(Captain,MOS72B/D*)FirstSergeant(MOS68S40*)Mechanic(MOS63B10*) PUBLICHEALTHTEAM13PreventiveMedicineSpecialists:MOS68S30MOS68S20MOS68S10 PUBLICHEALTHTEAM23PreventiveMedicineSpecialists:MOS68S30MOS68S20MOS68S10 PUBLICHEALTHTEAM33PreventiveMedicineSpecialists:MOS68S30MOS68S20MOS68S10 Figure1.CurrentUSArmyModifiedTableofOrganizationandEquipmentpersonnelallocationfortheLevelIIIPreventiveMedicineDetachment.*MOS(militaryoccupationalspecialty)glossary:72BEntomologist72DEnvironmentalScienceOfficer68SPreventiveMedicineSpecialist63BLight-WheelVehicleMechanic LevelIIIPreventiveMedicineinaCounterinsurgencyEnvironment

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AprilJune200829THEARMYMEDICALDEPARTMENTJOURNALSpecialist(MOS68J10)couldmanageallclassesofsupplyforthisnewdetachment.APMSpecialistcurrentlyperformslogisticsdutieswhichdrawstimeandeffortawayfromthePMmission.AssignmentofaMedicalLogisticsSpecialisttotheMTOEtomanageunitlogisticswouldliberatethePublicHealthSpecialiststoperformtheirpublichealthmission.Collectively,thesechangeswouldeliminateredundancy,increaseefficiency,andassisthostnationsinmeetingpublichealthneeds.TrainingFouryearsintotheIraqcounterinsurgency,thePMcommunitycontinuestofocussupportinternallyonCoalitionassetsratherthanexternallyonthecivilianpopulationandIraqiSecurityForces.Thislackofpublichealthintegrationexistsformanyreasons,somewithinandothersoutsideofDoDscontrol.Institutionaltrainingprovidesfertilegroundtoincreasethiscapacity. HEADQUARTERSCommander(Major,MOS72B/D/E*)ExecutiveOfficer(Captain,MOS72B/D/E*)FirstSergeant(MOS68RS40*)Mechanic(MOS63B10*)MedicalSupplySpecialist(MOS68J10*) PUBLICHEALTHTEAM13PreventiveMedicineSpecialists:MOS68RS30MOS68RS20MOS68RS10 PUBLICHEALTHTEAM23PreventiveMedicineSpecialists:MOS68RS30MOS68RS20MOS68RS10 PUBLICHEALTHTEAM33PreventiveMedicineSpecialists:MOS68RS30MOS68RS20MOS68RS10 PUBLICHEALTHTEAM4VeterinaryOfficer(Captain,MOS64B)VeterinaryTechnician(MOS68T10)MedicalLaboratoryTechnician(MOS68K10) Figure2.CurrentUSArmyModifiedTableofOrganizationandEquipmentpersonnelallocationfortheLevelIIIPreventiveMedicineDetachment.*MOS(militaryoccupationalspecialty)glossary:72BEntomologist72D/EEnvironmentalScience/EngineerOfficer68SPreventiveMedicineSpecialist63BLight-WheelVehicleMechanicTheconceptual68RSMOSwouldbecreatedasamergerofexistingMOSs68R,VeterinaryFoodInspectionSpecialist,and68S,PreventiveMedicineSpecialist.Team4isenvisionedasArmyMedicalDepartmentProfessionalOfficerFillerSystem(PROFIS)staffingbillets.PROFISpredesignatesqualifiedActiveDutyhealthprofessionalsservinginTableofDistributionandAllowance**unitstofillActiveDutyandearlydeployingandforwarddeployedunitsofForcesCommand,WesternCommand,andthemedicalcommandsoutsideofthecontinentalUnitedStatesuponmobilizationorupontheexecutionofacontingencyoperation.16Definesthestructureandequipmentforamilitaryorganizationorunit.**Prescribestheorganizationalstructure,personnelandequipmentauthorizations,andrequirementsofamilitaryunittoperformaspecificmissionforwhichthereisnoappropriatetableoforganizationandequipment.

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30www.cs.amedd.army.mil/references_publications.aspxAllArmyPMofficersattendthePrinciplesofMilitaryPreventiveMedicineindoctrinationcourse.Theprogramofinstruction(POI)consistsof585.4hoursofcommoncore,clinical,andsciencetrackinstruction.18Areviewofthecommoncoreandsciencetrackcourseswhicharecompletedbynoncliniciansrevealsthatonly11hours(3%)arefocusedonmaterialdirectlyorindirectlyrelatedtocounterinsurgencies(Table1).Althoughotherclasses,suchaswaterqualityanalysis,developcompetencieswhichcanbeappliedincounterinsurgencies,theseclassesdonotdrawcorrelationbetweenthetwo.Furtheranalysisrevealed14hoursofinstruction(Table2)providedduringtheclinicaltrackrelatetocounterinsurgencies.TheseclassesshouldbeincorporatedintothecommoncoretracktoincreasethecapabilitiesofallPMofficers.Seriousconsiderationshouldbegiventoaddingcourseshighlightingrootcausesofcounterinsur-genciesandeffectiveemploymentofArmyPMinsupportofcivil-militaryoperations.ConcurrentwithchangesintrainingdeliveredwithintheAMEDDPOIs,furtherdevelopmentofexternaltrainingmustalsobeaddressed.Aspreviouslyindicated,aggressiveeffortsweremadebythe61stMedicalDetachmenttoengageCApersonnel,withlittlereturnoninvestment.Thislimitedsuccesswascertainlynotduetoalackofeffort,rather,thedifficultieswerearesultofwhatwasroutinelyobservedasalackofeducation.CAofficersintheaterunderstoodthesignificantimpactwaterandsanitationhaveduringacounterinsurgency.Unfortunately,discussionswithbothseasonedandnewCAOfficersrevealedthattheyhadreceivedminimaltrainingonhowtoleveragePMinbridgingpublichealthgaps.CAdoctrinediscussesPM,butwhatemphasisisplacedonthisbattleoperatingsystemduringinitialtrainingisunknowntotheauthor.12AcomprehensiveanalysisoftheircoursePOIcouldidentifywheretrainingdeviatesfromdoctrine,andhowArmyPMcouldprovidetrainingassistance.Cross-trainingCAandPMpersonnelcouldcreateasymbioticrelationshipyieldingsubstantialdividendsduringcounterinsurgencies.RecentexperiencesinIraqcontinuetoidentifyprofoundshortfallsintheArmyFieldSanitationTeam(FST)program.19Theprogramisconceptuallyac-ceptedbyalllevelsofcommand,butimplementationislacking.ManyperceivetheFSTcourseasnothingmorethananavenuetoobtainenlistedpromotionpoints.Teammembersareassignedonpaperbutlosecurrencyorcompletethetaskonlyiftimepermits.MostunitcommandersdonotprocureFSTequipmentduetohighcosts,otherpriorities,andtime.TheestablishmentofasingleNationalStockNumbertostreamlinetheFSTkitwouldreducethetimespenttrackingnumerouslineitemsfoundinthecurrentkitandincreasecommandercompliance.ArmymedicsadoptedtheFSTresponsibilityinIraqwithdirectsupportfromLevelIIPMpersonnel.IsitmorepracticaltoaddFSTclassestotheArmymedicPOILevelIIIPreventiveMedicineinaCounterinsurgencyEnvironmentTitleHours ArmyHIVProgram 1IntroductiontoHumanitarianAssistanceOperations1 MalariaPrevention 1PreventiveMedicineSupportforDisasters1 PopulationHealth 1DisasterReliefPracticalExercises2 NutritionConcernsinDisasterRelief 2PreventiveMedicineAspectsofDetaineeOperations2Table1.Commoncore/sciencetrackcounterin-surgencyrelatedclassestaughtinUSArmyCourse6AF5-PrinciplesofMilitaryPreventiveMedicine. Table2.ClinicaltrackcounterinsurgencyrelatedclassestaughtinUSArmyCourse6AF5-PrinciplesofMilitaryPreventiveMedicine.TitleHoursRapidHealthAssessment1 PublicHealthAssessment 1CivilAffairsandForeignGovernmentLiaison2 ImplicationsofEmergingInfectiousDiseases 2PreventiveMedicineSupportinContingencyOperations8

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AprilJune200831THEARMYMEDICALDEPARTMENTJOURNALandhavethemassumethemission?ThismaybeadesirablesituationuponwhichtheArmyshouldcapitalize.AnetgaininFSTtrainingwasmadebythe61stMedicalDetachmentduringOIF06-08.ThedecisiontoshifttrainingfromCoalitionmemberstotheIraqiSecurityForceswasmadeuponarrival,andconsensuswasreachedatthestrategicleveltoreplicatethiseffortthroughouttheater.TraininghostnationmilitaryandcivilianpopulationsinPMisessentialtosustaintheirfightingforceandbuildbasicsanitationcapacity.Culturalimplementationofthesenewlyacquiredskillswillnotoccurovernight,buttheyareessentialinmeetingshortandlongtermneedsofthepopulation.MaterielCoalitionpersonnelinIraqareworkingalongsidetheISFandoperatingoutofausterejointsecuritystations.LevelIIIPMissupplyingsomeofthosestationsandArmy-ledMilitaryTransitionTeamswithbasicFSTequipmenttomeeturgentneedsincontrollingvectorsandpurifyingwater.Despitetheregulationrequirementforsupplies,theydonothavetheresourcesonhandformanyreasons.20ItshouldbeassumedthatsimilarscenarioswillexistinfuturecounterinsurgenciesandLevelIIIPMmustbeequippedwithadditionalkitstosupportthoseinneed.Insurgentswillcontinuetopursuetheuseoftoxicindustrialchemicalsandweaponsofmassdestruction.IncreasingtheLevelIIIdetachmentsdirectchemicalreadingcapabilitytomeasurecontaminantlevelsisacriticalrequirement.TheINFICON(TwoTechnologyPlace,EastSyracuse,NewYork13057)HAPSITEgaschromatograph/massspectrometer,andSmiths(SmithsDetection,21CommerceDrive,Danbury,CT06810)HazMatIDTMportablechemicalidentifierusedbytheArmyAreaMedicalLaboratoryandNavyForward-DeployedPreventiveMedicineUnitprovidethismuchneededcapability.NeitheroftheseLevelIVPMunitswereintheaterduringOIF06-08,whichplacedhigherexpectationsuponLevelIIIPMtoexecutemissionstheywereill-equippedtoperform.LeadershipThecurrentArmyPMleadershipwasshapedbyexperiencesduringthefirstGulfWar(1991)andtheBalkandeploymentsaconventionalwarandpeacekeepingoperations.MuchoftheirworkledtothedevelopmentandimplementationoftheOccupationalEnvironmentalHealthSurveillance(OEHS)programwhichiseasilyimplementedinalinearbattlefieldandsemipermissiveenvironment.21-23Thisprogramcapturesdatatoanalyzeacute,chronic,anddelayedhealtheffects,primarilythroughair,soil,andwatersampling.23RecenteventsinIraqledtoreprioritizingtheacutepublichealthneedsovertheOEHSsamplingmission.OEHSresultsfromtheUSArmyCenterforHealthPromotionandPreventiveMedicine(CHPPM)wereprovidedtothe61stMedicalDetachment,onaverage,91daysaftersampleshipmentforair,52daysforsoil,and59daysforwater.LevelIIPMexperiencedsimilarturnaroundtimesresultinginade-emphasisonOEHSsamplinginlieuofaddressingacuteneedsusingrealtimeanalysisequipment.ThiswascounterintuitiveforsomeLevelIIPMofficerswhoperceivedOEHSair,soil,andwatersamplecollectionastheirprimarymissionandlifelinetodefinitiveanswers.ThePMcommunityandleadershipmustaddresstheOEHSsamplinganddocumentationrequirementinacounterinsurgencyenvironmentwithresourcescurrentlyavailable.ItmaybemorerealistictohaveLevelIIandIIIPMpersonnelconductinitialbasecampOEHSsamplingwithintheirareasofoperationandLevelIVPMconductroutineandbasecampclosureOEHSsamplinginconjunctionwiththeArmyCorpsofEngineers.SeriousdiscussionmustalsoaddressthisrequirementandhowPMmeasureseffectiveness.OnecouldarguethatOEHSsamplingdoesnottiedirectlytoDNBIstatisticswhichisthecurrentdefaultmeasureofPMsuccessorfailure.TheeffectivenessofLevelIIIPMdetachmentsinthefieldisdirectlydependentonSoldiersthattheArmyrecruits,developsandplacesinpositionsofleadershipandcommand.Inthefinalanalysis,withoutdedicated,intelligent,well-trained,professionalleadership,noneoftheotherfactorsdiscussedhereinwillmatterintheperformanceofthesedetachments.Leadersinhighercommandpositionsmusthavethefullspectrumofinsightandunderstandingastothecapabilitiesandultimate,long-termstrategicvaluerepresentedbytheLevelIIIPMresource.Onlythenwilltheassetsbeintelligentlyappliedandadequatelysupported.Thatcommandperspectivecomesfromeducationandtraininginthestrategicconsiderationsofcounterinsurgencyoperations,combinedwiththeinsightsandunderstandingthatonlyresultfromactual

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32www.cs.amedd.army.mil/references_publications.aspxexperiencedevelopingandemployingtheLevelIIIPMresources.Overthenext5to10years,leaderswithinthePMcommunitywilldrawuponobservationsandlessonslearnedduringtheBalkandeploymentsandinitialphasesofOEFandOIF.Overthelongterm,LevelIIPMpersonnelcurrentlyservinginIraqwillassumeleadershiproles.Theircounterinsurgencyexperiencewilllikelydrivechangesincorecompetencies,withanemphasisonacuteandgeneralpublichealthintervention,tomeetwhatisperceivedbymanyastheconflictofthefuture.7,24,25PersonnelRecruitmentLevelIIIPMdetachmentsarecommandedbyfieldgradeEntomologist(MOS72B)andEnvironmentalScience/Engineer(MOS72D/E)officers,whichmakethese2specialtiesofparticularinterestinassessingrecruitmentandretention.TheArmyobjectiveforcefortheseofficersis346,withacurrentstrengthof335(97%fill).From2004to2006,theobjectiveforcefortheseprofessionswas72officers,ofwhom61(85%)arecommissioned.26Theyjoinedthroughdirectcommissionsfollowinggraduateschool,collegeReserveOfficerTrainingCorps,ortheUSMilitaryAcademy.Some,liketheauthor,converttoPMafterservingasaHealthCareAdministrativeAssistant(MOS70B).Assumingthatnotallofthe61commissionedofficerswillserveacareerinthemilitarycouldjustifypursuingotherrecruitmentavenues.AstudyassessingconversiontrendsfromMOS70BtotheMOS72seriesmayjustifyamarketingcampaigntorecruittheseofficerscomingoutofmultipleOIFrotations.TheywouldbringafirsthandunderstandingofhowPMcansupportthewarfighterduringacounterinsurgency.SupportingthefieldgradeLevelIIIPMdetachmentcommandersarecompanygradeexecutiveofficersservinginthesespecialtyareas.AreviewofactivedutyArmycompanygradeEnvironmentalScience/Engineerofficerauthorizationsrevealedthathalfwereingarrisonassignments.27Forty-sixpercentoflieutenantsand53%ofcaptainswereassignedtofieldunits,26%and25%respectivelytoCHPPM,and28%and22%respectivelytoArmymedicalcentersorotherorganizations.IntheperspectiveofanArmyatwar,thisappearsdisproportionatetothecurrentandfuturerequirements.In2006,theArmyPMConsultantposedasalientquestionintheArmyMedicalDepartmentJournal:ShouldsomeMEDDACESO[medicaldepartmentactivityenvironmentalscienceofficer]positionsbeconvertedundercurrentmilitary-to-civilianinitiativesinordertoprovidebetterdevelopmentalopportunitiesforjuniorofficerselsewhere?28Itcouldbearguedthereisnobetterplacetoapplyanddevelopskillsthanduringcombatdeploymentsbyconservingthefightingstrengthofthoseinharmsway.ReducinggarrisonpositionscouldshiftpersonneltomeetcurrentPMshortagesindeployablemultifunctionalmedicalbattalions,andaffordgrowthinareassuchasnewlyactivatedcivilaffairsbattalionsandeachregionalspecialoperationscommand.ExperienceintheseassignmentswouldgenerateskillsnecessarytoeffectivelyserveasbothaLevelIIIPMdetachmentexecutiveofficerandcommanderinacounterinsurgencyenvironment.SimilaranalysisshouldbecompletedtoassesstheproposedmergeroftheVeterinaryFoodInspectionSpecialist(MOS68R)andPreventiveMedicineSpecialist(MOS68S)intheenlistedforcestructure.Ultimately,theywillserveasLevelIIIPMdetachmentmembers,NCOs,anddetachmentsergeantswhoexecutetheunitmission.ItisimperativetosolicitfeedbackfrombothrecentlyreturnedandcurrentlydeployedPMandveterinarypersonnel,astheyunderstandthecurrentoperationalrequirements.AcomprehensivereviewofthemanningdocumentfortheexistingMOSsisnecessarytoshapefutureauthorizationsfortheproposedPublicHealthSpecialists(MOS68RS).Otherproposedchanges,suchasreplacingthecurrentMOS68Slevel10(PrivateFirstClassthroughSpecialist)ateachArmybrigadewithaMOS68Slevel30(StaffSergeant),mustbeconsidered,sincethesepositionswilldrivemanningrequirements.29PersonnelRetentionNumerousmediaoutletsdiscussthepotentialimpactofhighoperationaldemandsonretention.AccordingtotheDoD,Army,Navy,MarineCorps,andAirForcemetorexceededoverallretentionmissions.30WhatisnotclearareretentionratesinthePMcommunity.UnlikemostofficerswhoenterArmyPMwithadegreerelatedtotheirchosenfield,andwiththeintentionofdirectlyapplyingthateducation,enlistedPMpersonnelareselectedandtrainedbytheArmyinvariousskillsetsnecessaryfortheirMOS.Atspecificpointsintheenlistedcareerpath,theArmyoffersadditionaltrainingofincreasingsophisticationtoLevelIIIPreventiveMedicineinaCounterinsurgencyEnvironment

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AprilJune200833THEARMYMEDICALDEPARTMENTJOURNALsupporttheirrespectivespecialties.However,theArmyalsoregularlyoffersopportunitiesandincentivesforSoldierstochangetoanotherMOSspecialtyaltogether,dependingonstaffingprioritiesandshortfallsatthetime.AnySoldierconsideringalong-termcareerinPMwillevaluateopportunitiesintheirfieldagainstthoseopportunitiesrepresentedinanotherMOSorcivilianlife,andmakearationaldecision.WithlowpromotionratestoSergeantFirstClass(gradeE7)andabove,dueinparttothescarcityofseniorPMlevelpositions,thisweighsheavilyinthemindsofStaffSergeants(gradeE6).TheseNCOstypicallyhave10yearsinserviceanddebatewhethertocontinuetheirprofession,reclassify,orleavethemilitary.UnlessthePMenlistedauthorizationsareadjustedtosupportandencouragethepursuitofcareersbyourenlistedSoldiers,theeffectivenessandmanningofLevelIIIPMwillbelessthanoptimum.IncreasingseniorlevelenlistedPMauthorizationsallowingforprofessionalgrowthcommensuratewithtimeinvestedcouldmakeadifference.AddingMasterSergeant(gradeE8)positionstocombatantandotherstrategiccommandswhereEnvironmentalScience/Engineerofficerscurrentlyservewouldbeaforcemultiplier,allowforprofessionalgrowthandpromotion,andpositivelyimpactretentionrates.Additionally,investinginthelongtermeducationofbothmayprovideanimpetustoserveacareerinuniform.TheArmyPMleadershiptooktheinitiativein2004andcraftedaneducationandtrainingprogrambysendingEnvironmentalScienceofficerstotheUniformedServicesUniversityoftheHealthSciencestocompleteaone-yearMasterofPublicHealthdegreefollowedbyaone-yearutilizationtourinWashington,DC.Theseofficerscanspecializeinareassuchasinternationalhealthwhichhasapplicabilityinbothdisasterresponseandcounterinsurgencyoperations.Upongraduation,theofficercouldworkatDoDormilitaryserviceheadquarterslevels,orothergovernmentalagencies,suchastheDepartmentofStateorUSAgencyforInternationalDevelopment,applyingtheirskillstorealworldrequirements.AssignmentsinotheragenciesbroadentheirunderstandingofinteragencyoperationsandmeettheintentofDoDDirective3000.05,MilitarySupportforStability,Security,Transition,andReconstructionOperations31andtheQuadrennialDefenseReview.25FacilitiesProposedconsolidationofallservicesenlistedmedicaltrainingatFortSamHouston,TexasaspartoftheBaseRealignmentandClosureprocessiscommendedandshouldbereplicatedamongothermedicalspecialties.Consolidationoftrainingeffortscouldreduceduplicationinfacilities,operationsandmaintenancecosts,andpersonnelrequiredtoconductsimilartrainingprogramsat3differentserviceinstitutionswhileincreasingproductivityanddevelopingajointPMservicemember.ExperienceinIraqhighlightssimilaritiesincapabilitybetweenAirForce,Army,andNavyprofessionalsperformingPMtasks.CurrentdoctrinedrivesrequirementsforeachservicewheretheNavytraditionallyfocusedonmaritimeoperations,theAirForceonwingsupport,andtheArmyonthefootSoldier.InthecounterinsurgencyenvironmentofIraq,NavyEnvironmentalHealthofficersarecollocatedonforwardoperatingbaseswithArmySoldiers.AirForcePublicHealthandBioEnvironmentalEngineerofficers/techniciansareworkingshouldertoshoulderwithArmypersonnelonlargeairbases.The61stMedicalDetachmentprovidedgeneralareaPMsupporttoallservicepersonnelwithinmultinationaldivisionsinBaghdadandcentralIraqduringtheOIF06-08rotation.Additionally,all3servicesreceivedOEHSequipmentandlaboratorysupportfromtheUSArmyCenterforHealthPromotionandPreventiveMedicinefortheOEHSmissionwhiledeployedinIraq.Itisimperativethatleaderswithineachservicerecognizethesimilaritiesincapabilitiesandrequirementstodevelopacommonsetofknowledge,attitudes,andbeliefsforajointservicePMtrainingplatform.ThisplatformshouldbeinstitutionalizedataconsolidatedPMtrainingfacilityatFortSamHouston.CONCLUSIONThe2006DoDQuadrennialDefenseReviewstates:theabilitytowageirregularandunconventionalwar-fareandtheskillsneededforcounterinsurgency,stabilizationandreconstruction,militarydiplomacy,andcomplexinteragencycoalitionoperationsareessential.25AdoptionandimplementationoftheaforementionedDOTMLPFchangescouldfacilitatetransformationwithinthePMcommunitytomeetthesecurrentandfuturedemands,anddirectlysupportoverarchingUSgovernmenteffortsinrebuildingessentialservicesin

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34www.cs.amedd.army.mil/references_publications.aspxfragilesocieties.AsrecentlyobservedinIraq,andhighlightedbytheNationalSecurityStrategysignedbyPresidentGeorgeW.Bush:Militaryinvolvementmaybenecessarytostopabloodyconflict,butpeaceandstabilitywilllastonlyiffollow-oneffortstorestoreorderandrebuildaresuccessful.32PreventiveMedicinecansupportbothundertakings.REFERENCES 1.KrepinevichAFJr.TheArmyandVietnam.Baltimore,MD:JohnsHopkinsUniversityPress;1986:6.2.JointPublication1-02:DoDDictionaryofMilitaryandAssociatedTerms.Washington,DC:JointStaff,USDeptofDefense;July12,2007.Availableat:http://www.dtic.mil/doctrine/jel/new_pubs/jp1_02.pdf.3.FieldManual3-24:Counterinsurgency.Washington,DC:USDeptoftheArmy;15December2006:1-1,2-13.4.ChiarelliPW,MichaelisPR:Winningthepeace:therequirementforfull-spectrumoperations.MilRev.2005;4:4-17.5.FieldManual4-02.17:PreventiveMedicineServices.Washington,DC:USDeptoftheArmy;28August2000:4-1,4-10.6.FieldManual1:TheArmy.Washington,DC:USDeptoftheArmy;June2005:4-3,4-4.7.NaglJA.AbetterwarinIraq.ArmedForcesJ.August2006.Availableat:http://www.armedforcesjournal.com/2006/08/1931298.8.AhearnAM.VietCongmedicine.MilMed.1966;131:219-221.9.CarmonaRH.PresentationtotheNationalDisabledVeteransWinterSportsClinic.Aspen,CO:2003.10.FieldManual-Interim3-07.22:Counterinsurgency.Washington,DC:USDeptoftheArmy;1October2004.ReplacedbyFM3-24,2006.11.USDeptofState.FactSheetonProvincialReconstructionTeams.Baghdad,Iraq:EmbassyoftheUnitedStates;2006.12.FieldManual4-02.43:ForceHealthProtectionSupportforArmySpecialOperationsForces.Washington,DC:USDepartoftheArmy;27November2006:4-11,4-12.13.EricksonRL.MilitaryPreventiveMedicine:MobilizationandDeployment.Vol1.Washington,DC:BordenInstitute,OfficeoftheSurgeonGeneral,USDeptoftheArmy;2003:81-98.14.KeatingPJ.Moroccanfloodrelief:apersonalreport.MedBullUSArmyEur.1963;20(4):96-99.15.WebbCRJr.Medicalconsiderationsininternaldefenseanddevelopment.MilMed.1968;133:391-396.16.MedicalCorpsProfessionalDevelopmentGuide.FortSamHouston,TX:USArmyMedicalDepartmentCenterandSchool;March2002:27.17.FieldManual4-02.18:VeterinaryServiceTactics,Techniques,andProcedures.Washington,DC:USDeptoftheArmy;30December2004:1-1,4-7.18.USArmyMedicalDept.PrinciplesofMilitaryPreventiveMedicineProgramofInstruction.FortSamHouston,TX:USArmyMedicalDeptCenterandSchool;2003.19.FieldManual4-25.12:UnitFieldSanitationTeam.Washington,DC:USDeptoftheArmy;25January2002:1-1,2-75.20.ArmyRegulation40-5:PreventiveMedicine.Washington,DC:USDeptoftheArmy;25May2007:1-19.21.DepartmentofDefenseDirective6490.2:ComprehensiveHealthSurveillance.Washington,DC:USDeptofDefense;21October2004:1-6.22.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;11August2006:5-13.23.ArmyRegulation11-35:DeploymentOccupationalandEnvironmentalHealthRiskManagement.Washington,DC:USDeptoftheArmy;16May2007:1-9.24.HammesTX.TheSlingandTheStone..St.Paul,MN:ZenithPress;2004:xiii-xiv,224-291.25.OfficeoftheSecretaryofDefense.QuadrennialDefenseReviewReport.Washington,DC:USDeptofDefense;February6,2006.26.ArmyMedicalServiceCorps.CareerManagementHistograms.Alexandria,VA:USDeptoftheArmy;December2006.27.ArmyMedicalServiceCorps:MOS67CRoster.Alexandria,VA:USDeptoftheArmy;February2007.28.CieslaJJ.TheevolvingroleofEnvironmentalScienceOfficersandEnvironmentalEngineersintheMedicalServiceCorp.ArmyMedDeptJ.April-June2006:19.29.SamesWJ,DelkTC,LyonsPJ:Fieldpreventivemedicine:challengesforthefuture.ArmyMedDeptJ.April-June2006:43.LevelIIIPreventiveMedicineinaCounterinsurgencyEnvironment

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AprilJune200835THEARMYMEDICALDEPARTMENTJOURNAL30.DoDAnnouncesRecruitmentandRetentionNumbersforJune[pressrelease].Washington,DC:OfficeoftheAssistantSecretaryofDefense(PublicAffairs),USDeptofDefense:2007.31.DepartmentofDefenseDirective3000.05:MilitarySupportForStability,Security,Transition,AndReconstruction(SSTR)Operations.Washington,DC:USDeptofDefense;November28,2005:1-11.32.TheNationalSecurityStrategyoftheUnitedStatesofAmerica2006.Washington,DC:TheNationalSecurityCouncil,TheWhiteHouse;March2006:16.Availableat:http://www.whitehouse.gov/nsc/nss/2006/nss2006.pdf.AUTHORMAJLicinaisCommander,61stMedicalDetachment,86thCombatSupportHospital(CSH),FortCampbell,Kentucky.The86thCSHisapartofthe44thMedicalCommandatFortBragg,NorthCarolina. 86thCombatSupportHospital44thMedicalCommand

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36www.cs.amedd.army.mil/references_publications.aspxTheChemical,Biological,Radiological,andHighYieldExplosives(CBRNE)SciencesBranch*providestrainingtoadiversegroupofstudents,includingmembersofthevariousUSmilitaryservices,foreignstudents,andciviliansonmedicaloperationsonthenuclear,biological,chemical,ordirectedenergybattlefield;aswellasthesafeuseofradiationandradioactivematerials.In2007,theCBRNESciencesBranchtaughtthe5-dayTacticalRadiologicalOperations(TRO)CourseattheIdahoNationalLaboratory,IdahoFalls,ID.TheTROcoursewasdevelopedandhasevolvedinresponsetolessonslearnedafter4yearsofdeploymentsinsupportofOperationEnduringFreedom(OEF)andOperationIraqiFreedom(OIF).ThegapanalysissuggestedthattraditionalhealthphysicstrainingdesignedforhospitalandgarrisonenvironmentsdidnotprovidetheinstructionandfocusthatNuclearMedicalScienceOfficersneedwhendealingwithradiologicalhazardsinnonmaturetheatersofoperation.TheregulatoryconstraintsontheuseoflicensedradioactivemateriallimittheabilityoftheArmyMedicalDepartmentCenterandSchool(AMEDDC&S)toproviderealworldsituationswherehealthphysicstrainingwouldmorecloselyreplicatedeploymentandhomelanddefensescenarios.AttheIdahoNationalLaboratory,theDepartmentofEnergywasabletoprovide,atonelocation,accesstoauniquecombinationoffacilities,radioactivematerials,andtrainedprofessionalstaffthatcannotbeduplicatedatanyDepartmentofDefensefacility.Inordertobridgetraininggaps,theCBRNESciencesBranchandtheUSArmyChemicalSchoolcoordinatedwiththeIdahoNationalLaboratorytoaccommodateOEFandOIFscenario-drivenenvironmentalhealthphysicstrainingformilitarypersonnel.TheTROcourseconsistsofdidactichealthphysicstraining,radiationdetection/identificationequipmenttraining,highenergyradioactivesourceidentificationandquantification,andradiologicaldispersaldevicetrainingthatculminatedwithafieldtrainingexerciseincorporatingbasicmilitaryskillsandteamtechnicalskills.Itisalsodesignedtofacilitatesmallteamtrainingandinteractionwithtrainingscenariostoprovideopportunitiesforbothindividualleadershipdevelopmentandteamproblemsolving.AcrosstheArmymanpowerstructure,therearemanydifferentmilitaryoccupationalskillsthathavesimilarmilitaryknowledgerequirements.Thisistrueforradiologicaloperationsforsomemedical,chemicalcorps,andengineeringdisciplines.Inordertobroadentheavailabilityofqualitysubjectmatterexpertstoaddressmultiplemissionrequirementsforsuchspecialists,theTROcourseisofferedforEnviron-mentalScienceandEngineeringOfficersandChem-icalOperationsSpecialists.The2007scenariosincluded:TacticalmovementofasurveyteamintoalocationtoconductabasecampassessmentforradiologicalhazardsHighenergyradioactivesourceidentificationandmitigationtoincludeexposureguidanceforpersonnelDecontaminationofpersonnelexposedtoweaponsgradeorothernuclearmaterielEncounterswithmediapersonnelregardingpotentialradioactivecontaminationtomilitaryandhostnationpersonnelPreparingtheForcefortheChemical,Biological,Radiological,andHighYieldExplosivesBattlefield;TodayandTomorrowLTCGaryMatcek,MS,USAScottCrail,MSSFCCourtneyMoore,USAJamesBernardo *DepartmentofPreventiveHealthServices,AMEDDCenterandSchool

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AprilJune200837Thecriticaltasksaccomplishedwere:Selectionoftheproperradiationdetection/identificationequipmentforagivenmission.Properoperationofradiationdetection/identificationequipmentforagivenmission.DesignradiologicalsurveyusingTechnicalGuide236A;BasicRadiologicalDoseEstimationAFieldGuide,1andthenbriefthebrigadecommander.Conductradiologicalsurveyofareatoincludesoil,air,andwatersampling.TESTINGANDFIELDINGNEWEQUIPMENTRecently,theCBRNESciencesBranchparticipatedinseveralmeetingsaboutthedevelopmentofthenewXM-329JointChemical,BiologicalandRadiologicalAgentWaterMonitoringSystem(JCBRAWM).ThesystemisunderdevelopmentbytheUSChemicalCorpstoaugmenttheM272WaterTestKitinresponsetotheArmysidentificationoftheneedtoexpandtheM272capabilitytoincludethefullspectrumofCBRNEthreats.Therequirementforexpansionincapabilitiesistheresultofrecentthreatsintheareasofhomelandsecurityandhomelanddefense.TheJCBRAWMconsistsoftheAN/PDR-77RadiacDetectorSetwhichtestswaterforpossibleradiologicalcontamination,theHandHeldAssayforpossiblebiologicalcontamination,andthestandardM272WaterTestKitforchemicalcontamination.AstheNuclearMedicalScienceOfficersandPreventiveMedicineSpecialistsexecutetheirwartimemissionofbasecampassessment,theenhancedcapabilityprovidedbytheJCBRAWMwillfurtherimprovethesafetyandsurvivabilityofallSoldiersonthebattlefieldbyensuringthatwatersourcesareatanacceptablelevelofcleanlinessandpurificationforconsumption.Inaddition,itwillincreasethecapabilityoftheUSChemicalCorpstoidentifywhichnaturalormanmadewatersourcesshouldorshouldnotbeusedforpersonalorequipmentdecontamination.Asafurthercomplementtothetypeofequipmentthatwillbeusedtosampleandtestwater,theUSChemicalCorpshasenhancedtheimmediatepersonneldecontaminationcapabilityoftheArmybydevelopingtheReactiveSkinDecontaminationLotion(RSDL).ThenewlotionprovidesaSoldierwiththecapabilitytoperformon-the-spotdecontaminationwithoutthenecessityofthefullspectrumdecontaminationlineamanpowerintensiveprocess.ThroughtheuseoftheJCBRAWMandtheRSDL,thePreventiveMedicineSpecialistwillnowhavetheabilitytoconducton-the-spotchemical,biological,andradiologicaltesting,withtheaddedcapabilityforpersonalandequipmentdecontamination.BothAMEDDandtheChemicalCorpswillbenefitfromtheserecentnewequipmentdevelopments.EventhoughJCBRAWMdevelopmenttestingisnotcomplete,theCBRNESciencesBranchwillcontinuetorepresenttheArmyMedicalCommandinadvisingthedevelopmentalteamtoensureoptimumusabilitybyPreventiveMedicineSpecialists.ASTANDARDOFPROFICIENCYFORFIXEDMEDICALTREATMENTFACILITIESINALL-HAZARDSRESPONSEAhazardousmaterialincidentinvolvingCBRNEhazardsorotherthreats,whetheraccidentalorintentional,hasthepotentialtoproducecatastrophiclossoflifeorproperty,orstriketerrorintheaffectedpopulation.AnincidentmayoccurintheUSoroverseas.TheArmyTrainingandEvaluationPlanMissionTrainingPlanforUSArmyfixedinstallationmedicaltreatmentfacilities(MTF)provideshospitalandcliniccommandersandstaffwithadescriptive,missionorientedprogramtotrainthefacilitystafftoperformitscriticaloperationsduringsuchanevent.JointChemical,Biological,andRadiologicalAgentWaterMonitoringSystem(JCBRAWM)

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38www.cs.amedd.army.mil/references_publications.aspxWhileUSArmyMedicalCommanddirectives,nationalhealthcarestandards,andlocalconditionsandproceduresdictateuniquetrainingrequirementsandperformancestandards,theMissionTrainingPlandescribesmanyofthetasksthatanystaffofahospitalorclinicmaybecalledupontoexecutewithahighlevelofproficiency.ThecommanderofeachfacilityisnotexpectedtotrainoneverysingletaskintheMissionTrainingPlan;rather,tasksareselectedandprioritizedbasedonanassessmentofanMTFsstrengthsandweaknesses,andonthosetasksthatfocusontrainingdeficienciesthatimpactontheMTFsabilitytoperformitsfirstreceivermission.TheCBRNEScienceBranchwasassignedthetasktodevelopanArmyTrainingandEvaluationPlancontainingindividual,collective,andleadertasksforfixedmilitaryMTFstosupportinstallationprotectionmissionsandplansforCBRNEandallotherhazards.Thetrainingdocumentstraditionallyhaveaunit/activitydoctrinalmanualtoprovideoperatingprinciplesandtechniquesthatallowthetrainingdevelopertoanalyzeandenumeratecollectivetasksfortheentity.Inthiscase,therewasnobaselinepublicationforfixedinstallationMTFs,thus,theteamreliedonanextensiveliteraturereviewtohelpdevelopthetasks.Theunit,leader,andindividualtrainingsyllabisupporttheaccomplishmentofbothHomelandSecuritymissionsandtraditionalfullspectrummilitaryoperations.Therefore,currentdoctrinalmanuals,ArmyTrainingandEvaluationPlanMissionTrainingPlans,andfederalgovernmentresponseguidelinesofferawealthofinformationontrainingtasksthatcanbeadaptedforinstallationMTFs.AccordingtotheArmyTrainingandDoctrineCommandRegulation350-70,2arevisionoftasksratherthanafull-scaledevelopmentaleffortispreferredfortrainingsimilarmissionsinadifferentenvironmentorsetting.Byidentifyingtasksfromcurrentdocumentation,theteamcanbuildabasicoutlinefromwhichtofurtheranalyzeandrefinerequiredCBRNEtasksforafixedMTF.Oncecandidatetaskshavebeendefined,amission/jobanalysismuststillbeconductedtoidentifycriticalcollectivetasks.Thisisakeystep,sincethecollectivetasksperformedtoaccomplishaunitorMTFmissionwilldrivethedevelopmentorrevisionofindividualandleadertasksthatdirectlysupportthemission.Missionanalysisidentifiesunitorganizationalandfunctionalstructurebeforedevelopmentofunittrainingproducts.Armedwithbaselinecollective,leader,andindividualtasks,membersoftheteamandagovernmentrepresentativewillconductsitevisitstoMTFs.ThisisrequiredtoreceiveinputfromtheMTFcommanderandstaffandtoanalyzecandidatetaskswithinthecontextofexistinginstallationplansandstandardoperatingprocedures.Asaresultofsitevisitsandcontinuinganalysisanddevelopment,alistofproposedcollective,leader,andindividualtasksarepresentedforreview.AnexampleofproposedtasksinsupportofCBRNEeventsare:PerformpublichealthemergencyofficerfunctionsConductterminationplanningConductinteragencycoordinationReviewandupdateCBRNEincidentresponseplanAtaskvalidationboardorsomeotherproponentmechanismwillthenbeconvenedforfurtherreviewandselectiontoapprovetheproposedtasks.Oncethatapprovalisreceived,thetrainingdeveloperswillenterthetasksintotheAutomatedSystemsApproachtoTraining.Thetrainers/evaluatorswilldevelopandpresentatrainingevaluationplanbasedontheapprovedcollective,leader,andindividualtasks.Trainingevaluationistheprocessusedtoidentifytaskperformanceanddeficienciesinunitandindividualtraining,andtoobtainrecommendationsforimprovementoftraining,ortheproductsthatsupporttraining.ThereisnospecificprocedureprescribedforArmyTrainingandDoctrineCommandproponentsinthedevelopmentorconductofunittrainingevaluation.Theproceduresselectedaredependentuponavarietyoffactors,including,inthiscase,theMTFreal-worldworkload,whethertheunitcanbevisitedbyexternalevaluators,whetheractualtrainingexecutioncanbeobserved,andhowmanyunitpersonnelareavailabletoparticipateinanexerciseorotherevaluationvehicle.Byitsverynature,CBRNEresponseexercisesinaHomelandSecurityscenariorequireenormousamountsofcoordinationandresourcesfromlocal,state,andfederalagenciesandroleplayerstoprovidePreparingtheForcefortheChemical,Biological,Radiological,andHighYieldExplosivesBattlefield;TodayandTomorrow

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AprilJune200839THEARMYMEDICALDEPARTMENTJOURNALthepropertestconditions.Therefore,standardArmyandAMEDDevaluationregimensmayyieldtotheDepartmentofHomelandSecurityand/orstateemergencymanagementevaluationschedulesandrequirements.IndividualandleadertaskevaluationscanbedoneintheschoolhouseorattheMTFsbyuseofstudentperformancemeasurementandtesting,includingpracticalexercise,andthereforelendthemselvestoaregularassessmentschedulewithouttheneedforalargecommitmentofresources.TheevaluatorswilltakethesefactorsandAMEDDguidanceintoaccountindevelopmentoftheevaluationplan.TrainingandevaluationexercisesforafixedMTFareinherentlydifficultforthecommanderforavarietyofreasons.Mostnotably,thehospitalorclinicmustperformreal-worldmissions,resultinginseveretimeandresourceconstraintsfortrainingmissions,whichimpactpersonnelavailabilityissues.Despitetheneedtoperformday-to-dayoperations,thefacilitymusttrainandundergoperiodicevaluationsinaccordancewithdirectives,notonlyfromhighercommand,butfromcivilianagenciessuchastheJointCommissiononAccreditationofHealthcareOrganizationsandtheDepartmentofHomelandSecurity.ThestrategyselectedbythecommanderfortrainingMTFdepartmentsmustincludevariousmethodsoftrainingindividuals,designatedstaff,leaders,andthedepartmentandfacilitystaffsasawhole.ACKNOWLEDGEMENTTheauthorsgratefullyacknowledgetheassistanceofEricBodenhausen,JosePerez,andDougHansonfortheireditorialreviewandcomments.REFERENCES 1.TechnicalGuide236A,BasicRadiologicalDoseEstimationAFieldGuide.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine;August15,2001.Availableat:http://chppm-www.apgea.army.mil/documents/tg/techguid/tg236a.pdf.2.TRADOCRegulation350-70:SystemsApproachtoTrainingManagement,Processes,andProducts.FortMonroe,VA:USArmyTrainingandDoctrineCommand;March9,1999:chapII-11.Availableat:http://www-tradoc.army.mil/tpubs/regs/r350-70/350_70_ii_11.htm. AUTHORSLTCMatcekistheOfficerinCharge,CBRNESciencesBranch,DepartmentofPreventiveHealthServices,AMEDDCenterandSchool,FortSamHouston,Texas.ScottCrailisaSeniorRadiologicalCBRNEInstructor,CBRNESciencesBranch,DepartmentofPreventiveHealthServices,AMEDDCenterandSchool,FortSamHouston,Texas.SFCMooreistheNoncommissionedOfficerinCharge,CBRNESciencesBranch,DepartmentofPreventiveHealthServices,AMEDDCenterandSchool,FortSamHouston,Texas.MrBernardoisaProjectManager,TrainingDeveloper,andInstructor,CBRNESciencesBranch,DepartmentofPreventiveHealthServices,AMEDDCenterandSchool,FortSamHouston,Texas.

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40www.cs.amedd.army.mil/references_publications.aspxOVERVIEWOn15September2005,PresidentBushendorsedtheDepartmentofDefense(DoD)BaseClosureandRealignmentCommissions(BRAC)reportandforwardedittoCongress.Thecongresshad45legislativedays,untilNovember9,2005,toacceptorrejectthereportinitsentirety.However,itwasnotauthorizedtomakeanychangestothefinalreport.1Sincethecongresstooknoactionbeforethedeadline,theBRACrecommendationsbecamelaw.Bystatute,DoDhaduntilSeptember15,2007,toinitiateclosingandrealigningtheinstallationsspecifiedinthereport.Additionally,theprocessmustbecompletedbySeptember15,2011.2IncludedintheBRACrecommendationswasCommissionRecommendation172,SanAntonioRegionalMedicalCenter,Texas.3ItiswithinthisrecommendationthattheconceptoftheMedicalEducationandTrainingCampus(originallysubmittedunderBRACastheMedicalEnlistedTrainingCenter)wasestablished.Therecommendationspecificallywastorelocateall(exceptAerospaceMedicine)medicalbasicandspecialtyenlistedtrainingatFortSamHouston,Texas,withthepotentialoftransitioningtoajointtrainingeffort.4InresponsetotherequirementfortheMedicalEducationandTrainingCampus,theArmyMedicalDepartmentCenterandSchool(AMEDDC&S)directeditssubordinateteachingdepartmentstocoordinatewiththeInterserviceTrainingReviewOrganization(ITRO).TheITROthenconductedmeetingsamongtheservicestodetermineifcourseswouldcollocateorintegrate.Thespecifiedconstructwas:QuickLookGroupDetailedAnalysisGroupResourcesRequiredAnalysisWhilethisprocessisuniformforall,theremainderofthisarticlewillfocusonitsapplicationtoPreventiveMedicine.QUICKLOOKGROUPThePreventiveMedicineQuickLookGroup,composedoftheArmy68S10*ProgramManager,ClassAdvisor,andInstructionalSystemsSpecialist;andtheNavyProgramManager,ServiceLead,andInstructionalSystemsSpecialist;alongwithvariousITROstaff,metfromSeptember12-14,2006.This3-dayinitialstudyrevealedsufficientcommonalityexistingbetweentheUSArmyPreventiveMedicineSpecialistCourseandtheUSNavyPreventiveMedicineTechnicianCoursetoproposeconsolidatingamajorityofthetrainingandrecommendcontinuingtheITROprocess.ThemembersofthisQuickLookGroupagreedtofuturemeetingstodevelopaconsolidatedcurriculumandidentifycomputerbasedtrainingopportunities.Itwasagreedthatmembershipofthesestudiesshouldincludethecurrentparticipants.TheQuickLookGroupmadethefollowingspecificrecommendations:Ensureajointservicescurriculumandrequiredsupportfacilitieswillbeincompliancewithcurrentcertification/accreditationrequirements.Coordinateproposedfacilitiesplanswithservicesubjectmatterexperts.DuetoshipboardandFleetMarineForcetrainingrequirements,NavystudentsmusthavephaseII,Navyspecificsites(ie,shipboardtraining).PhaseIIsiteswillrequirededicatedinstructorstaff.5(p6)TheArmyPreventiveMedicineSpecialistintheMedicalEducationandTrainingCampusEraLTCDennisB.Kilian,MS,USASFCRoyeL.Patton,USAHMCSWilliamAdams,USN *ArmyMilitaryOccupationalSpecialty68S10,PreventiveMedicineSpecialistArmyTrainingCourse322-68S10NavyTrainingCourseHM8432

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AprilJune200841SincetheUSAirForceenlistedpreventivemedicinepersonnelareconsideredpartoftheaerospacemedicinecommunity,theirtrainingwillrelocatefromBrooksCityBase,SanAntonio,TX,toWright-Patter-sonAirForceBase,Dayton,OH.Consequently,theAirForceisnotpartoftheBRAC-drivenpreventivemedicinetrainingreviewandreorganization.DETAILEDANALYSISGROUPThemeetingofthePreventiveMedicineDetailedAnalysisGroupwasheldMarch6-8,2007.ThemilitarytrainingpersonnelwhowerepreviouslypartoftheQuickLookGroupconductedanin-depthanalysisofthe2programsofinstruction(POI)conductedinthetrainingofservicespecificpreventivemedicinepersonnel.TheArmytrainsPreventiveMedicineSpecialists(MilitaryOccupationalSpecialty68S10)for15weeks(75academicdays)attheAMEDDC&S,FortSamHouston,Texas.Forplanningfactors,theArmytrainingrequirementforFiscalYear(FY)2010is209students.Thebasiccourse*consistsof532hoursofdidactic/laboratory/practicaltraining,and110hoursoffieldtrainingexercisesandsituationaltrainingexercisesatotalof642academichours.AtthetimeofreviewbytheDetailedAnalysisGroup,therewere7classiterationsperyear,withamaximumclasspopulationof32students,minimumof12students,andanaverageof21.TheenrollmentpaygradeforActiveArmySoldiersisE4orbelow,E6orbelowformembersoftheReserveComponent.AsapartofthePOI,studentsmustpassspecifiedareasoftheDoDPestManagementCertificationexam.Additionally,theyareofferedtheopportunitytotaketheServSafecertificationexamination.TheNavytrainsPreventiveMedicineTechnicians(PMT)for26weeks(130academicdays)attheNavalSchoolofHealthSciences,SanDiego,California.TheNavytrainingrequirementforFY2010is160students.TheNavyusesmultipleclinicalandfieldtrainingsites,includingships,fixedfacilities,andlocalcivilianfacilities.ThePMTbasiccourseconsistsof844hoursofdidactic/laboratory/practicaltraining(includinga160-hourcourse:MedicalEntomologyandPestManagementTechnologyforPMTs),and64hoursofotherrequiredtrainingandactivities.Thetrainingtotals1,040hours.AtthetimeofreviewbytheDetailedAnalysisGroup,therewere4classiterationsperyear,withamaximumclasspopulationof40students,minimumof20students,andanaverageof40.TheenrollmentpaygradeforactivedutyNavyisE3throughE7.ThiscourseisopentoNavyReserveandCoastGuardpersonnel.AsapartofthePOI,studentsarerequiredtopassspecifiedpestmanagementcategoriesoftheDoDPestManagementCertificationexam.StudentsmaytaketheCertifiedEnvironmentalHealthTechnicianexamfromtheNationalEnvironmentalHealthAssociation.5(p6)DuringtheDetailedAnalysisGroupworkingsessions,theArmyandNavyrepresentativespresentedseveralconcernsforfurtherexamination:ArmyAMEDDC&Swillbeabletocontinuetoinviteinternationalstudentstoattendpreventivemedicinetraining.EnsurethatfoodservicesanitationremainsinthecurriculumtoenableArmystudentstosuccessfullypasstheServSafeExam.5(p5)NavyScopeofpracticeaconcernbecauseNavyPMTsoperateclinically,unlikeArmypreventivemedicinepersonnel.CoursecontentconsideredanopportunitysinceJointOccupationalandEnvironmentalHealthSurveillanceislargelyundocumentedintheNavyPOI5(p5)(currentrequirementsdrivenbyaDoDDirective,6aDoDInstruction,7andamemorandumfromtheChairmanoftheJointChiefsofStaff8).RequirementforaPhaseIIclinicalsitesincetherearenoshipboardenvironmenttrainingfacilitiesatFortSamHouston,teachingshipboardpracticeswouldbeproblematic.Accreditation/certificationsmaintainingaccredi-tation/certificationswasviewedasacriticalrequirement,whichisconsistentwithotherprogramsrelocatingandintegratingintotheMedicalEducationandTrainingCampusconcept. *ArmyTrainingCourse322-68S10TheServSafeFoodSafetyCertificationisariskmanagementprogramoftheNationalRestaurantAssociationEducationalFoundation.ServSafeisthemostwidelyacceptedfoodsafetyprogramamonglocal,state,andfederalhealthdepartments.Informationavailableathttp://www.nraef.org.

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42www.cs.amedd.army.mil/references_publications.aspxAsaresultoftheworkofthePreventiveMedicineDetailedAnalysisGroup,arecommendationforthecoreconsolidationofapproximately449hoursofinstructionwassubmitted.TheresultanttotalArmycourselengthwillbe642hours,theNavycourselengthwillbe1,120hours.Withineachsyllabus,449hoursofinstructionwillbepresentedinajointformat.5(p7)RESOURCEREQUIREMENTSANALYSISThePreventiveMedicineResourcesRequiredAnalysiswasconductedattheAMEDDC&S,August14-16,2007.Thefollowingweretheareasoffocusduringthesessions:Manpoweranalystsidentifiedinstructor,averagedaily studentload,andstudentman-yearrequirements.TherepresentativesreviewedthecoursemodeldatadevelopedduringtheDetailedAnalysisGroup.Thegroupconsensuswasaconsolidatedlectureratioof2:56(lateramendedto2:61).Thediscussionfocusedontherequirementtodividestudentsintogroupswitharatioof1instructorforevery6studentsduringthemajorityoftheconsolidatedlaboratoryexercises.Serviceinstructorsexpressedconcernsthatinstructor/studentratiosshouldbepreserved.Thisconcernwasduetothefactthatproperinstructor/studentratioswerenotinitiallybeingmaintainedduringoverlappingiterations(overlappingiterationsdriverequirementsto21instructors,withoutregardtoservice).Themanpowercostmodelinitiallyauthorized17instructors(8Navy,9Army).Afterfurtheranalysis,21instructors(10Navy,11Army)wereauthorized,therebyresolvingconcernsaboutinstructor/studentratios.Theinitialclasssizewas56students(36Army,20Navy)with6projectedclassiterations.9Thesenumberswererevisedatthedesigncharrette*fortheMedicalEducationandTrainingCampusbuildings3and4,raisingclasssizeto61students(35Army,26Navy).Facilitiesanalystsdidanin-depthreviewtoidentifyall requirementsneededtosupporttraining.TheanalystsusedFY2010yearofexecutiondataandservicestudentnumbersforallstudies.Theanalysts,inconjunctionwithservicesubjectmatterexperts,determinedtheconsolidatedandintegratedenlistedpreventivemedicineinstructionalfacilitywouldhave4laboratories:microbiology/wateranalysis(Figure1),industrialhygiene(Figure2),medicalentomology,whichwouldhaveanassociatedsmallmultifunctionlabprimarilyusedbytheNavyforclinicalaspectsofpublichealth(Figure3).Inaddition,4studentlectureclassroomsweredesigned:onefor61studentsinajointlectureenvironment,onefor36studentsforArmyspecificlecture,and2classrooms,eachseating26studentsforNavyspecificlectures.ResourcesRequiredAnalysisattendeesmetwiththe MedicalEducationandTrainingCampus/TransitionIntegrationOffice(METC/TIO)stafftodetermineequipmentrequirements,manpoweroverhead,andtheconceptofoperations.TheMETC/TIOstaffalsodiscussedacademic concernsregardingcurriculumdevelopment,clinicalsites,andaccreditationandcertificationissues.9(p3)TheNavyrepresentativesexpressedseveralconcerns relativetoacademicsandassociatedaccreditationandcertification.Forexample,theProgramDirectormustbeacredentialed(gradeO5)EnvironmentalHealthOfficerorArmyequivalentEnvironmentalScience *Afinal,intensiveefforttofinishaprojectbeforeadead-line.Source:RandomHouseUnabridgedDictionary.NewYork,NY:RandomHouse,Inc;2006. Figure1.Plannedpreventivemedicinemicrobiology/wateranalysislaboratoryclassroom(61students,1,661sqft)fortheconsolidatedandintegratedenlistedpreventivemedicineinstructionalfacilityatFortSamHouston,Texas.TheArmyPreventiveMedicineSpecialistintheMedicalEducationandTrainingCampusEra

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AprilJune200843THEARMYMEDICALDEPARTMENTJOURNAL Figure3.Plannedpreventivemedicinemedicalentomologylaboratoryclassroom(2,548sqft)fortheconsolidatedandintegratedenlistedpreventivemedicineinstructionalfacilityatFortSamHouston,Texas. Figure2.Plannedpreventivemedicineindustrialhygienelaboratoryclassroom(2,905sqft)fortheconsolidatedandintegratedenlistedpreventivemedicineinstructionalfacilityatFortSamHouston,Texas.

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44www.cs.amedd.army.mil/references_publications.aspxandEngineeringOfficer(ESEO)tomeetrequirementswhichallowNavystudentstositforcertificationexams.Aspreviouslydiscussed,NavyPMTsarecurrentlyeligiblefortheNationalEnvironmentalHealthAssociationprofessionalcertification*asaCertifiedEnvironmentalHealthTechnician(CEHT).TheNavyPMTstaketheCEHTexaminationattheendoftheentirecurriculum(includingclinicaltraining)priortotransfertotheirnextdutystation.NavyPMTsareeligiblefortheexaminationbasedonthecurrentNavycurriculumwhichallowsthestudenttoearn48to60semesterhoursofcredittowardstheBachelorofScience(HealthSciences)degreecompletionprogramatselectedcollegesanduniversities.10SincetheArmyrequirescredentialcertificationofallfieldgradeESEOs,11theNavyagreedtotherotationofthedirectorshipofthisprogram.DESIGNCHARRETTEAftertheResourcesRequiredAnalysis,theMETCleadershipteamheldaseriesofdesigncharrettes,whichincludedAMEDDC&Spreventivemedicinerepresentatives,toaddresseachoftheMedicalInstructionalFacilities(MIF)(preventivemedicineisassignedtoMIF-4).Itiswithinthisprocessthatdetailedrequirementsforlaboratories,classrooms,whiteboards,smartpodiums,etc,weredocumented.Theresultsofthiseffortyieldedaformalrequestforproposal,which,atthetimethisarticlewaswritten,hadnotbeenreleased.CONCLUSIONTheUSArmyhasinvestedheavilyinthefutureofpreventivemedicine.Theyhavedrivendetailedanalysesoftime,programsofinstruction,andequipmentandfacilitiesrequiredtoproducetheSoldiersoftomorrow.Makenomistake,thefutureoftheArmyPreventiveMedicineSpecialistisbright.FromInitialEntryTraining/AdvancedIndividualTraining,ourSoldierswillhavethebenefitofworkingandlearninginajointservicesenvironment.Whiletheinitiativeforaunifiedmedicalcommandwasnotadoptedbecauseofthesignificantdifferencesinorganization,responsibilities,andoperationsofUSAirForcepreventivemedicineassetsrelativetotheArmyandNavy,theServiceshavebeendirectedbytheDeputySecretaryofDefenseintoanewgovernanceplan.12Thisplanfocusesonmedicalresearch,medicaleducationandtraining,healthcaredeliveryinmajormarkets,andsharedsupportservices.Whilethisdoesnotincludebattlefieldhealthcare,theprimaryandmostcrucialreasonforconsideringaunifiedmedicalcommand,theArmyPreventiveMedicineSpecialistandNavyPreventiveMedicineTechnicianwillreapthebenefitsofBRAC2005Recommendation172.3ThisisbecausebothArmyandNavypreventivemedicinepersonnelserveininfantryunitstheArmybrigadecombatteamandtheNavyintheMarineCorpsinfantrybattalion.Currently,inIraqandAfghanistantherearecountlessexamplesofArmyandNavypreventivemedicineunitsworkingbothinteroperablyandinterchangeably,furtheringDoDsForceHealthProtectionrequirements.BystartingthisorientationofourSoldiersattheearliestpointintheirArmycareer,theArmyandNavywillonlyimprovethisrequirement.REFERENCES 1.GilmoreGJ.PresidentsendsBRACcommissionreporttoCongress[DeptofDefenseinformationwebsite].September16,2005.Availableat:http://www.defenselink.mil/news/newsarticle.aspx?id=17278.AccessedJanuary17,2008.2.MilesD.BRACdeadlineexpires;DoDtobeginclosures,realignments[DeptofDefenseinformationwebsite].November9,2008.Availableat:http://www.defenselink.mil/news/newsarticle.aspx?id=18352.AccessedJanuary17,2008.3.USDeptofDefense.2005BaseClosureandRealignmentCommissionReport.Vol1.Arlington,Virginia:DefenseBaseClosureandRealignmentCommission;September8,2005:262.Availableat:http://www.brac.gov/docs/final/Volume1BRACReport.pdf.AccessedApril17,2008.4.MedicalJointCrossServiceGroup.Annex.X:MedicalJointCrossServiceGroupReportforBRAC2005.Arlington,Virginia:DefenseBaseClosureandRealignmentCommission,MedicalJointCrossServiceGroup;May9,2005:43.Availableat:http://www.defenselink.mil/brac/pdf/VolX_Medical-o.pdf.AccessedJanuary17,2008.5.HealthCareInterserviceTrainingOffice.DetailedAnalysisGroupReport:6-8March2007.SanDiego,California;NavalSchoolofHealthSciences;2007:3.6.DepartmentofDefenseDirective6490.02E;ComprehensiveHealthSurveillance.Washington,DC:USDeptofDefense;October21,2004.TheArmyPreventiveMedicineSpecialistintheMedicalEducationandTrainingCampusEra *Informationavailableat:http://www.neha.org/credential/

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AprilJune200845THEARMYMEDICALDEPARTMENTJOURNAL7.DepartmentofDefenseInstruction6490.03;DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.8.OfficeoftheChairman,JointChiefsofStaff.MemorandumMCM0028-07,ProceduresforDeploymentHealthSurveillance.WashingtonDC:USDeptofDefense;November2,2007.Availableat:http://amsa.army.mil/Documents/JCS_PDFs/MCM-0028-07.pdf.9.HealthCareInterserviceTrainingOffice.ResourceRequirementsAnalysisSummaryReport:June-September2007.FortSamHouston,Texas;USArmyMedicalDeptCenterandSchool;2007:3.10.HealthCareInterserviceTrainingOffice.PreventiveMedicineSpecialist:PreventiveMedicineTechnician:ResourceRequirementsAnalysisReport:14-16August2007.FortSamHouston,Texas;USArmyMedicalDeptCenterandSchool;2007:4.11.ArmyPamphlet600-4;ArmyMedicalDepartmentOfficerDevelopmentandCareerManagement.Washington,DC:USDeptoftheArmy;June27,2007:78.12.PhilpottT.Rejectedmedicalcommand[Military.comwebsite].December16,2006.Availableat:http://www.military.com/features/0,15240,120543,00.html.AccessedJanuary27,2008.AUTHORS LTCKilianisChief,EnvironmentalQualityBranch,andProgramManagerfor68S10,DepartmentofPreventiveHealthServices,AMEDDC&S,FortSamHouston,Texas.SFCPattonistheNoncommissionedOfficerinCharge,EnvironmentalQualityBranch,andClassAdvisorfor68S10,DepartmentofPreventiveHealthServices,AMEDDC&S,FortSamHouston,Texas.Atthetimethisarticlewaswritten,HMCSAdamswastheServiceLead,PreventiveMedicineTechnicianCourse,NavalSchoolofHealthSciences,SanDiego,California.HeiscurrentlytheCommandMasterChief,USSReubenJames(FFG-57). TheUSArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas

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46www.cs.amedd.army.mil/references_publications.aspxINTRODUCTIONArthropod-bornepathogensthatcausediseases,suchasmalaria,yellowfever,anddengue,aremajorhealththreatstothemilitary.Forexample,lossestomalariaandotherpreventablediseasesamongAlliedforcesoperatingintheChina-Burma-IndiatheaterduringWorldWarIIfarexceededthenumberofcasualtiesinflictedbyenemyaction.1MalariawassecondonlytocombatinjuryasthereasonforhospitalizationamongAmericantroopsinVietnam,andthenumberonereasonfortroopsdeployedtoSomalia.2AsignificantproportionofJointTaskForcepersonnelinsertedintoLiberiainAugust2003(80outof290whohadbeenashore)experiencedsymptomsofmalaria.3InfectedtroopsreturningtotheUnitedStatesincreasetherateofimportedmalaria.4Anophelesmosquitospeciesaresolelyresponsibleforglobalmalariacases.Over450speciesofAnophelesareknown,butonlyafractionaremalariavectors.Morepreciseinformationontheactualandpotentialgeographicdistributionofthespeciesresponsibleformalariacouldassistahostofhealth-relatedactions,includingpredeploymentcounsellingforprophylaxis;thechoiceofhealthmessagesduringdeployment;decisionsastothelocationsofrefugeecamps,hospitals,andbases;postdeploymentevaluationofhealthriskexposures;selectionofthetypeandextentofvectorcontrol;thechoiceofvectoridentificationtools;identificationofthelikelyvectorforaregion;andmanagementorquarantineofinvasivevectorandparasitespecies.Recently,computerprogramshavebecomeavailablethatcombineclimateinformationwithdataonwhereorganismshavebeencollectedtoproducemapsofthepotentialdistributionoftheseorganisms.5,6Avarietyofmosquitospecieshavebeenmodeledinthisway.7,8Theoutputfromthesemodels,usuallythesuitabilityforoccurrenceofaparticularspecies,canbeextendedtoaresolutionofonekm2orless.Thezonewherehumans,parasitesandvectorsco-occurconstitutesageographicareaofmalariariskthatwedubthemal-area(seeFigure1).Themal-areacanberegardedastheecologicalnicheorpotentialspatialextentofthisdisease.9Asubsetoftheecologicalnicheisthemal-areaofcurrenttransmission,whichexpandsandcontractsaccordingtothelevelofmosquitosurvivalandabundance,human-vectorcontact,andcasedetectionandMalariaRiskAssessmentfortheRepublicofKoreaBasedonModelsofMosquitoDistributionDesmondH.Foley,PhDCOL(Ret)TerryA.Klein,MS,USAHeungChulKim,PhDRichardC.Wilkerson,PhDLeopoldoM.Rueda,PhD ABSTRACTDataonclimate,environment,andadultandlarvalmosquitocollectionsitesthroughouttheRepublicofKorea(ROK)wereusedtomodelthepotentialdistributionofthe8anophelinespeciesknowntooccurthere.ThesemodelswereoverlaidonpredictedareasofmalariasuitabilitytobetterdefinethedistributionofmalariariskintheROK.Theconceptofthemal-areaanareaofco-occurrenceofhumans,parasitesandvectors,wheremalariatransmissionispossibleisexplained.Quantificationofthemal-areainthevicinityof5militaryinstallationsinthenorthofthecountrysuggestedthattheyhadverydifferentmalariarisks,dependingonwhatthevectorspecieswere,andthemethodofcalculation.Anonlinemal-areacalculatorformalariariskassessment(currentlyunderdevelopment)isdiscussed.

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AprilJune200847treatment,amongamyriadofotherfactors.BecausethePlasmodiumparasiteisnormallydependentonahumanormosquitohost,themal-areashouldapproximatethespatialextentoftheparasite.Thephenomenonofanophelismwithoutmalariadescribestheareawherevectorsandhumans,butnotparasites,co-occur,eg,manypopulatedpartsoftheUnitedStateshavemalariavectorsbutthediseasewaseradicatedthere.Untilrecently,detailedintelligenceonthedistributionofvectorswasnotavailableformalariariskmodels.TheMalariaAtlasProject10(MAP)modelsthelimitsofactualmalariatransmissionusinginformationoninternationaltravel-healthguidelinesandestimatesofvectoroccurrence,fromaltitudeanddegreeofurbanizationdata.11Fine-tuningsuchmapsofglobalmalariasuitabilitybyincorporatingdetailedmosquitospeciesdistributionmodelscouldprovideaclearerpictureofareasofheightenedmalariarisk.Theresultingmal-areaextentcouldbeusedasasimpleindextocomparemalariariskbetweenlocationsofinterest(Figure1).Specifically,mal-areamappingcouldimproveforcehealthprotectioninareasofoperationsuchastheRepublicofKorea(ROK)thathaveahistoryofmalariatransmission.Priortothe1950s,PlasmodiumvivaxmalariawasendemicandwidespreadintheROK,12suggestingthatthepotentialmal-areaisextensiveinthatcountry.Malariawaseradicatedinthe1970sbutreemergedin1993andreachedapeakof4142casesin2000beforefallingto774casesin2004.13MostmalariacasesappeartohavebeencontractedneartheDemilitarizedZone(DMZ)thatseparatesNorthandSouthKorea.13Thisisreflectedinthenortherlylocationoftheareaofcurrentmalariasuitability,asdeterminedbytheMAPmodels(seeFigure2).TheanophelinefaunaofSouthKorea(ie,theROK)isrelativelywellresolvedtaxonomically,14-16andongoingmosquitosurveillancemakesthiscountryanideallocationtotestthemal-areaapproachtoassessingmalariarisk.TheanophelinefaunaoftheROKincludes8species:Anophelessinensissensustricto(s.s.)WiedemannAn.pullusM.Yamada(=An.yatsushiroensis)An.lesteriBaisas&Hu(=An.anthropophagus)An.sineroidesS.YamadaAn.kleiniRuedaAn.belenraeRuedaAn.lindesayijaponicusS.YamadaAn.koreicusS.Yamada&WatanabeThesespeciesarenotallidentifiablebasedonmorphology,butapolymerasechainreaction(PCR)techniquehasbeendevelopedforspeciesidentification.15Historically,An.sinensiswasconsideredtheprimaryvector.However,thediscoveryofadditionalspeciesandresultsfromfieldandlaboratoryparasitestudieshavecombinedtopointtoAn.kleini,An.pullus,andAn.sinensisasthelikelyvectorsaroundtheDMZ.13Logically,sincefurthermosquitoandparasitesamplingisrequired,allspeciescouldberegardedaspotentialvectors. Figure1.Illustrationoftheconceptofthemal-areaasitappliestomalariariskassessmentingeographicspace.Presence/absenceofhumans(H),areasofsuitabilityforPlasmodiumspecies(P),andpredicteddistributionofmalariavectors(V)areshown,aswellasthemal-area(VPH);theareaofoverlapwheremalariatransmissionispossible.Histogramshowsthepercentageofthesampledareathattheseparameterscover.ThevalueforVPHcouldbeusedasasimplifiedindexofmalariarisktocomparedifferentareas.

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48www.cs.amedd.army.mil/references_publications.aspxWeusedclimateandadultandlarvalmosquitocollectiondatafromsitesthroughouttheROKtomodelthedistributionofall8anophelinespecies.TobetterunderstandthedistributionofmalariariskintheROK,especiallyaroundmilitaryinstallationsinthenorthofthecountry,theresultingmodelsofpotentialspeciesdistributionswerecomparedwithareasofmalariasuitability.Anonlinemal-areacalculatorformalariariskassessmentthatisunderdevelopmentisdiscussedlaterinthisarticle.MATERIALSANDMETHODSAdultmosquitosurveillancewasconductedatselectedUSmilitaryinstallationsusingNewJerseylighttraps(JohnW.HockCo,Gainesville,FL)andMosquitoMagnets(WoodstreamCorporation,Lititz,PA)(Figure3),andlarvalcollectionsweremadethroughouttheROK.AdultsandlarvaewereidentifiedtospeciesbycomparisonofDNAproductsproducedbyPCR.15WeusedtheGeneticAlgorithmforRule-setPrediction(GARP)5,17andamaximumentropyapproach,knownasMaxent,6,18fordistributionmodelling.GARPusesaniterativeprocessofruleselection,evaluation,testing,andincorporationorrejection.ThegeneticalgorithminGARPallowstherulestoevolvetomaximizepredictiveaccuracy.Aruleisselectedandisappliedtohalfthepoints(trainingdata)andmodelsassessedwiththeotherhalfofthepoints(testingdata).Thechangeinpredictivitybetweeniterationsisusedtoevaluatewhetheraparticularruleshouldbeincorporatedintothemodel.Maxentisbasedontheideathatthebestexplanationforunknownphenomenawillmaximizetheentropyoftheprobabilitydistribution,subjecttotheconstraintoftheenvironmentalconditionswherespecieshavebeendetected.Outputwaspredictedprobabilityofpresence.Themethodologyandresultsofthismodellingwillbereportedingreaterdetailinaforthcomingpaper.Weobtainedaltitudeandaselectionofclimategridlayersfor1980through1990fromWorldclim,19fivelayerssummarizingaspectsoftopographyandlandform(topographicindex,slope,aspect,flowdirection,andflowaccumulation)fromtheUSGeologicalSurveysHYDRO-1KElevationDerivativeDatabase,20datalayerssummarizingthegreennessindextermedtheNormalizedDifferenceVegetationIndex21fromtheAdvancedVeryHighResolutionRadiometersatellitedatapresentingpercentagetreecoverfor1992-1993,thirteenclassesofland-use/land-coverfromtheGlobalLandCoverFacility,22soiltaxonomysubordersoftheworldfromtheUSDepartmentofAgricultureNationalSoilsConservationService,23anddataonareasequippedforirrigationfromtheAquastatsiteoftheFoodandAgricultureOrganizationoftheUnitedNations.24Figure2.LocationsofmosquitocollectionpointsintheROKusedinspeciesdistributionmodelling.Alsodepictedistheextentoftheareapredictedactiveformalaria.(DataderivedfromtheMalariaAtlasProject.10Datafromtheboxedareawasusedformal-areacalculations. Figure3.TheMosquitoMagnetusespropanetoproduceCO2andheattoattractinsectvectorswhicharecaughtinthevacuumanddepositedinthecollectionbag. MalariaRiskAssessmentfortheRepublicofKoreaBasedonModelsofMosquitoDistribution

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AprilJune200849THEARMYMEDICALDEPARTMENTJOURNALInall,79one-km2environmentaldatalayerswereavailable,whichwereducedto15byprincipalcomponentsanalysis(PCA)inMinitab15.1.1.0(MinitabInc,StateCollegePA)priortomosquitodistributionmodelling.The15PClayersexplainedmorethan95%oftheoverallvariationinthe79environmentalparameters.WeimporteddataintoArcView3.3(ESRI,Redlands,CA)forimageanalysis.ThecurrentspatiallimitsofP.vivaxintheROKweretakenfromtheMAPwebsite10andresampledforone-km2resolutiontomatchthatofthemosquitodistributionmodels(seeFigure2).Weassumedthathumanpopulationdensitythroughouttheareasofinterestwassufficientformalariatransmission.Weapplieda10-kmradiusbufferaround5selectedUSmilitaryinstallationsinthenortheastoftheROK.UsingArcView3.3,weconductedmapqueriesfor3scenariosforpossibleareasofcoincidenceofvectorsandmalariawithinthebuffers,wherefalse=0andtrue=1.Wealsoconductedamapcalculationforafourthscenariowherenocoincidenceofvectorsandmalaria=0,onevectorspeciescoincidingwithmalaria=1,twospeciescoinciding=2,andthreespeciescoincidingwithmalaria=3.Inscenario1,onlyonespecies,An.sinensis,isconsideredavector,ashadbeenassumedbyworkersinthepast.Scenario2assumesthatanyofthe8anophelinespeciesoccurringintheROKcantransmitmalariaiftheyco-occurwiththespatiallimitsofparasites.Thisisthemostconservativescenario.Scenario3assumesAn.kleini,An.pullus,andAn.sinensisarevectors,ashasbeensuggestedintheliterature.13Inthisscenariotheco-occurrenceofanyorallofthesespecieswiththemalariasuitableareaisscoredastrue(=1)forthepurposesofthemal-areacalculation.Scenario4assumesAn.kleini,An.pullus,andAn.sinensisarevectors,butthattheriskincreasesifmorethanonespeciesco-occurswiththemalariasuitablearea.Thesespecieswereequallyweighted,asdefinitiveinformationontheirrelativevectorialimportanceislacking.Thetotalnumberofone-km2pixelsscoredtrueforthefirst3scenarios,andthesumofvaluesforthesepixelsforthefourthscenariowerecalculatedforthebufferedareassurroundingthe5installations.Figure4.ExamplesofMaxentmodelsofthepotentialdistributionfor2anophelinespeciesintheROK,basedonmosquitocollectiondataandenvironmentaldatalayers.Darkershadingindicatesgreaterpredictedsuitabilityofthatareafortheoccurrenceofthatspecies.

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50www.cs.amedd.army.mil/references_publications.aspxRESULTSMosquitoeswereidentifiedtospeciesfromatotalof174collectionlocationsintheROKfromcollectionsfrom1998through2006(seeFigure2).Someofthesedatawerereportedpreviously.25DistributionmodelsrevealedthatAn.sinensis,An.kleini,An.pullus,andAn.belenraewerepredictedtooccurwidely,whereasAn.lesteriispredictedtooccuronlyinnorthwestareasoftheROK(Figure4).ExamplesofoutputfromMaxentmodelsforAn.kleiniandAn.lesteriarepresentedinFigure4.CollectiondataanddistributionmapswillbeavailablefromtheMosquitoMapwebsite*andinafuturepublication.AllspeciesarepredictedtooccurinthenorthoftheROKwheremalariahasbeenmostcommonsinceitfirstreappearedin1993.Mal-areacalculationsforthe4scenariosareshowninFigure5.Inallscenarios,CampHumphreyshasnomalariatransmissionriskduetoitfallingoutsidethepredictedspatiallimitsofmalariaasgivenontheMAPwebsite.10Comparisonofthemal-areascores(Figure6)revealsthatCampHumphreysandKwangsa-rihavethelowestvalues.Thescoresforscenario4arehigherthanfortheotherscenarios,reflectingthecumulativeeffectofvectorspeciesoccurrencesonmalariarisk.Intheseexamples,therankofthemalariariskofthe5installationsdoesnotchangemarkedlywiththedifferentscenarios,exceptthatColbernhasahigherscorefortheAn.sinensis-onlyscenario.DISCUSSIONArthropod-borneinfectiousdiseasesareamajorhealththreattoourcombattroops.WecannotaffordtoignorethishealththreatnorrepeatthemistakesofpreviousconflictswheremanySoldiersweredebilitatedorkilledbypreventableinfectiousdiseases.Knowledgeoftheidentityandoccurrenceofthemajorvectorsisaprimerequirementtodeterminethethreatposedbyvector-bornediseases.Predictingwherethevectorsarelikelytobefoundcouldbeavaluableadditiontohealthriskassessmentanddiseasecontrolstrategies.Asstandardizedandaccessibletechniquesformodellingthedistributionofdiseasevectorsarerecentdevelopments,theapproachgivenhereisnew.Applicationofmodelsofvectordistributiontodiseaseriskassessmentisalogicalnextstep.Wehaveshownthatasimpleindexoftheareawheredisease *http://www.mosquitomap.org Figure5.Fourscenariosoftheextentofthemal-areaformalariawithin10kmof5USmilitaryinstallationsintheROK(one-km2pixelresolution),basedonvectordistributionmodelsandtheareaspredictedsuitableformalaria,fromtheMalariaAtlasProject.10Darkerareasindicategreaterriskofmalaria.Legend:A.Anophelessinensisistheonlyvector.B.Anyofthe8AnophelesspeciesknownfromtheROKarepresent.C.Anyof3species(An.kleini,An.sinensisandAn.pullus)ispresent. MalariaRiskAssessmentfortheRepublicofKoreaBasedonModelsofMosquitoDistribution

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AprilJune200851THEARMYMEDICALDEPARTMENTJOURNALtransmissionispossible,themal-area,canbeusedtoassessdiseaseriskfora10kmradiusbufferaroundUSmilitaryinstallationsintheROK.Althoughanysizeareacanbeconsidered,a10-kmbufferisappropriatetocalculatethehealthriskarisingfromthelocalenvironment,ortheamountofvectorcontrolneededwithinabarrierzonearoundthesepoints.Wehaveshownthatthemethodofcalculatingthemal-areaisanimportantvariable.Identificationofthevectorspecies,andtheweightattachedtothesespeciesintermsofvectorialimportanceisalsocritical.However,theaccuracy,scale,andprecisionofmodelsofvectorandparasitedistributionisoffundamentalimportance.ItshouldbenotedthatlittleinformationisavailableformalariainNorthKorea11andsothemalariousareamayextendfurthernorththanshownhere.TheWorldHealthOrganizationreportedthatamalariaepidemicoccurredinNorthKoreashortlyafterthefirstcaseofmalariareemergedalongtheDMZin1993,suggestingaparalleloutbreakoccurredinbothcountries.26Themal-areacalculationsshownheredonotyettakeintoaccountseasonality,useofinsecticidebednets,humanmovement,socio-economiclevel,ormanyothervariablesthatmodifytheprevalenceandincidenceofmalaria.Inaddition,vectordistributionmodelspredictgeneralhabitatsuitability,butfactorsnotincludedinthesemodelsincludehistorical,physical,climatological,andbioticconstraintsthatmayplayaroleinlimitingpotentialdistribution.Evaluatingandimprovingvectormodelaccuracyisanongoingtask,butbettermodelscanbeeasilyincorporatedastheybecomeavailable.Despitethesimplifiedassumptionsofthemal-areamethodofriskassessmentshownhere,theapproachispotentiallyveryquickandcanbeusedforanyareaofinterestintheworld,evenwheremedicalintelligenceissketchy.Onecanseethelocationofthemal-areawithintheareaofinterest,orthemal-areacanbe Figure6.Mal-areacalculationsinnumberofone-km2pixelsformalariawithin10kmof5USmilitaryinstallationsintheROK,basedonvectordistributionmodelsandtheareaspredictedsuitableformalaria,fromtheMalariaAtlasProject.

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52www.cs.amedd.army.mil/references_publications.aspxreducedtoasinglefiguretocompareriskbetweenareas.Intheabsenceofotherintelligence,themal-areaapproachhaspotentialasafirstapproximationofrisk.Alternatively,vectorandmal-areamapscanbeusedasbaselayersinmorecomplexepidemiologicalGISdiseaseriskmodels.Agenericmal-areatoolcouldconceivablybeusedtomeasureanyriskfactor,includingothervector-bornediseases,wherespatialmodelsoftheriskcomponentsareavailable.Suchatoolwouldhavegreatvalueformedicalintelligenceestimates,particularlywhenforcesaredeployedtohostilelocationsforthefirsttime.WeareconstructinghighresolutionmapsofpotentialgeographicaldistributionofaselectionofmosquitovectorsofdiseasewhichwillsoonbeavailableviatheMosquitoMapwebsite,anonlineclearinghouseforgeoreferencedmosquitocollectionrecords,andspeciesdistributionmodelsderivedfromthoserecords.MosquitoMapusesArcGISServer9.2toenablethequeryandmappingofgeoreferencedmosquitocollectionrecordsaspointsorcountry-levelaggregations.Datacomefromrecordsheldbymuseums,scientificliterature,andprivatecollections.Currentlythereare65,000records,mainlyforAustralasiaandtheNeotropics.AnapplicationwithinMosquitoMap,themal-areacalculator,isdesignedtoprovideafast,easy,andintuitiveinterfaceforrapidlyassessingrelativemalariarisk.Theintentionisfortheusertodefinealocationorareaanywhereonthefaceoftheearthandthecalculatorcombinesmodelsofdiseasedistributionwithpredicteddistributionofmajordiseasevectors.Basedonthelocationorareadefined,anHTMLand/orPDFchartwillberenderedthatgraphsstatisticsforgridlayersofvariouscombinationsoftheVPHvariables.Thesestatisticswillconsistofthepercentageofcellsthatcontainacertainvaluefortheuserdefinedarea.MosquitoMapandthemal-areacalculatorrelyondistributionmodelsforallvectorspecies,butthesearecurrentlylacking.However,theseapplicationsprovideaframeworktohostandanalyzefuturevectoranddiseasemodelsastheybecomeavailable.ACKNOWLEDGEMENTFundingforthisprojectwasprovidedbytheDepartmentofDefenseGlobalEmergingInfectionsSurveillanceandResponseSystem,SilverSpring,MD(projectNo.G00018_08_WR).WethankA.TownsendPetersonforadviceregardingdistributionmodelling.WethankLCDRJean-PaulChretienforadviceandsupport.ThisresearchwasperformedunderaMemorandumofUnderstandingbetweentheWalterReedArmyInstituteofResearchandtheSmithsonianInstitution,withinstitutionalsupportprovidedbybothorganizations.REFERENCES 1.StoneJH,ed.CrisisFleeting.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;1969.2.MalariaFoundationInternational.FAQs.Availableat:http://www.malaria.org/travelhealth.html.3.SmithAM,HooperC.Themosquitocanbemoredangerousthanthemortarround.Theobligationsofcommand.NavWarCollRev.2005;58(1):77-87.Availableat:http://www.nwc.navy.mil/press/review/documents/NWCRW05.pdf.4.BarrettO.Malaria:epidemiology.In:OgnibeneAJ,BarrettO,eds.InternalMedicineinVietnam.VolumeII,GeneralMedicineandInfectiousDiseases.Washington,DC:OfficeofTheSurgeonGeneral,USDeptoftheArmy;1982:279-291.5.PereiraRS.DesktopGARP.2002.Availableat:http://www.lifemapper.org/desktopgarp/.6.PhillipsSJ.Maxentsoftwareforspecieshabitatmodeling,ver.2.2.0.2006.Availableat:http://www.cs.princeton.edu/~shapire/maxent/.7.LevineRS,PetersonAT,BenedictMQ.GeographicandecologicdistributionsoftheAnophelesgambiaeComplexpredictedusingageneticalgorithm.AmJTropMedHyg.2004;70:105109.8.MoffettA,ShackelfordN,SarkarS.MalariainAfrica:vectorspeciesnichemodelsandrelativeriskmaps.PloSONE.2007;2(9):e824.doi:10.1371/journal.pone.0000824.9.PetersonAT.Ecologicalnichemodellingandunderstandingthegeographyofdiseasetransmission.VetItaliana.2007;43:393-400.10.MalariaAtlasProjectwebsite.Availableat:http://www.map.ox.ac.uk/MAP_overview.html.11.GuerraCA,SnowRW,HaySI.Definingtheglobalspatiallimitsofmalariatransmission.AdvancesinParasitol.2006;62:157-179.12.ReeH-IL.UnstablevivaxmalariainKorea.KoreanJParasitol.2000;38:119-138.MalariaRiskAssessmentfortheRepublicofKoreaBasedonModelsofMosquitoDistribution

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AprilJune200853THEARMYMEDICALDEPARTMENTJOURNAL13.LeeW-J,KleinTA,KimH-C,ChoiY-M,YoonS-H,ChangK-S,ChongS-T,LeeI-Y,JonesJW,JacobsJS,SattabongkotJ,ParkJ-S.Anopheleskleini,Anophelespullus,andAnophelessinensis:potentialvectorsofPlasmodiumvivaxintheRepublicofKorea.JMedEntomol.2007;44(6):1086-1090.14.WilkersonRC,LiC,RuedaLM,KimHC,KleinTA,SongGH,StrickmanD.MolecularconfirmationofAnopheles(Anopheles)lesterifromtheRepublicofSouthKoreaanditsgeneticidentitywithAn.(Ano.)anthropophagusfromChina(Diptera:Culicidae).Zootaxa.2003;378:1-14.15.LiC,LeeJS,GroebnerJL,KimH-C,KleinTA,OGuinnML,WilkersonRC.AnewlyrecognizedspeciesintheAnophelesHyrcanusGroupandmolecularidentificationofrelatedspeciesfromtheRepublicofSouthKorea(Diptera:Culicidae).Zootaxa.2005;939:1-8.16.RuedaLM.TwonewspeciesofAnopheles(Anopheles)HyrcanusGroup(Diptera:Culicidae)fromtheRepublicofSouthKorea.Zootaxa.2005;941:1-26.17.StockwellDRB,NobleIR.Inductionofsetsofrulesfromanimaldistributiondata:arobustandinformativemethodofanalysis.MathComputSimul.1992;33:385-390.18.PhillipsSJ,AndersonRP,SchapireRE.Maximumentropymodelingofspeciesgeographicdistributions.Ecol.Modell.2006;190:231-259.19.HijmansRJ,CameronS,ParraJ.WorldClim[data-baseonline].Availableathttp://www.worldclim.org/.20.HYDRO1khomepage.USGeologicalSurveywebsite.Availableat:http://edc.usgs.gov/products/elevation/gtopo30/hydro/.21.MODISNormalizedDifferenceVegetationIndexpage.UniversityofMarylandGlobalLandCoverFacilitywebsite.Availableat:http://glcf.umiacs.umd.edu/data/ndvi/.22.LandCoverClassificationpage.UniversityofMary-landGlobalLandCoverFacilitywebsite.Availableat:http://glcf.umiacs.umd.edu/data/landcover/.23.GlobalSoilsRegionMap.USDeptofAgricultureNationalResourcesConservationServicewebsite.Availableat:http://soils.usda.gov/use/worldsoils/mapindex/order.html.24.AQUASTATresourcespage.FoodandAgricultureOrganizationoftheUnitedNationswebsite.Availableat:http://www.fao.org/nr/water/aquastat/main/index.stm.25.RuedaLM,KimH-C,KleinTA,PecorJE,LiC,SithiprasasnaR,DebbounM,WilkersonRC.DistributionandlarvalhabitatcharacteristicsofAnophelesHyrcanusGroupandrelatedmosquitospecies(Diptera:Culicidae)inSouthKorea.JVectorEcol.2006;31:198-205.26.HanET,LeeDH,ParkKD,SeokWS,KimYS,TsuboiT,ShinEH,ChaiJY.Reemergingvivaxmalaria:changingpatternsofannualincidenceandcontrolprogramsintheRepublicofKorea.KoreanJParasitol.2006;44:285-294. AUTHORSDrFoleyisaResearchEntomologistattheWalterReedBiosystematicsUnitoftheDivisionofEntomology,WalterReedArmyInstituteofResearch,basedattheSmithsonianInstitutionMuseumSupportCenter,Suitland,Maryland.COL(Ret)KleinisaconsultantwithForceHealthProtection,18thMedicalCommand,Unit15281,YongsanGarrison,Seoul,RepublicofKorea.DrKimisaResearchEntomologistwiththe5thMedicalDetachment,168thMedicalBattalion(AS),18thMedicalCommand,Unit15247,YongsanGarrison,Seoul,RepublicofKorea.DrWilkersonisaResearchEntomologistandManagerattheWalterReedBiosystematicsUnitoftheDivisionofEntomology,WalterReedArmyInstituteofResearch,basedattheSmithsonianInstitutionMuseumSupportCenter,Suitland,Maryland.DrRuedaisaResearchEntomologistattheWalterReedBiosystematicsUnitoftheDivisionofEntomology,WalterReedArmyInstituteofResearch,basedattheSmithsonianInstitutionMuseumSupportCenter,Suitland,Maryland.

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54www.cs.amedd.army.mil/references_publications.aspxABSTRACTTheUSAirForcehashadalonghistoryofaerialapplicationsofpesticidestofulfillavarietyofmissions,themostimportantbeingtheprotectionoftroopsthroughtheminimizationofarthropodvectorscapableofdiseasetransmission.BeginninginWorldWarII,aerialapplicationofpesticidesbythemilitaryhaseffectivelycontrolledvectorandnuisancepestpopulationsinavarietyofenvironments.Currently,themilitaryaerialspraycapabilityresidesintheUSAirForceReserve(USAFR),whichoperatesandmaintainsC-130airplanescapableofavarietyofmissions,includingultralowvolumeapplicationsforvectorandnuisancepests,aswellashighervolumeaerialapplicationsofherbicidesandoil-spilldispersants.TheUSAFRaerialsprayassetsaretheonlysuchfixed-wingaerialsprayassetswithintheDepartmentofDefense.Inadditiontotroopprotection,theUSAFRAerialSprayUnithasparticipatedinanumberofhumanitarian/reliefmissions,mostrecentlyintheresponsetothe2005HurricanesKatrinaandRita,whichheavilydamagedtheGulfCoastsofLouisiana,Mississippi,andTexas.ThisarticleprovideshistoricalbackgroundontheAirForceAerialSprayUnitanddescribestheoperationsinLouisianaintheaftermathofHurricaneKatrina.INTRODUCTIONHumanhealthhaslongbeenatriskfromarthropod-bornediseases.Malaria,dengue,WestNilevirus,andotherscontinuetocausehumanhealthproblemsandcreatemediaattention.Militaryentomologistsareacutelyawareofthediseasethreattodeployedtroopsfrominsectpests,andhaveremainedanintegralpartoftheDepartmentofDefense(DoD)sincetheywereemployedwithexcellentresultstocombatmalariaintheSouthPacificduringWorldWarII.1Inthatconflict,militaryentomologistsquicklydevelopedeffectivestrategiestocontrolmosquitoesandmaintaintroophealth.Onesuchmethodwastheapplicationofinsecticidesfromaircrafttoareaswithhighmosquitoactivity.Aerialapplicationsofpesticidesareaneffectivewayofrapidlyreducingnumbersofpotentialinsectvectorsacrosslargeareasandinarelativelyshortperiodoftime.2-5Unliketruck-mountedsprayunitsorbackpacksprayers,aircraftcanaccessdevelopedandundevelopedareaswhicharepronetoarthropodoutbreaks.TheAirForcehasthemissiontoprovideafixed-wing,large-area,aerialpesticideapplicationcapabilitytocontroldiseasevectors,pestorganisms,andundesirable/invasivevegetation,aswellastreatoilspillsincombatareas,onDoDinstallations,orinresponsetodeclaredemergencies.Inaddition,DoDrequirestheAirForcetoprovidetrainingtoaircrewsandgroundsupportpersonnelintheprinciplesandpracticesofaerialpesticideapplication.TheAirForceAerialSprayUnit(AFASU)tracesitshistorybacktoearlyaerialapplicationsofDDTduringthelaterstagesofWorldWarII.Aftertheendofthewar,theSpecialDDTFlightwascreatedin1946,butwassoontransformedtotheSpecialAerialSprayFlight(SASF)in1947whentheAirForcebecameaseparatearmedservice.6Eventually,asUSmilitaryoperationsinVietnamwerereducedintheearly1970s,activedutyAirForceassetsweremovedtoreservestatus,includingsprayplanesreturningfromOperationRanchHanddefoliationflightsinVietnam.7Aftermorethan25yearsatLangleyAirForceBase,Virginia,theSASFwastransferredfromtheactiveAirForcetotheAirForceReservein1973.Priortothistransfer,theSASFhadsprayedformosquitoes,Japanesebeetles,andfireantsinvariouslocationsattherequestoftheArmy,Navy,andotherfederalagencies.ThemovetotheAirForceReserveresultedinachangeoflocationanddesignation.RelocatedtoRickenbackerAirForceBase,Ohio,theunitwasTheUSAirForceAerialSprayUnit:AHistoryofLargeAreaDiseaseVectorControlOperations,WWIIThroughKatrinaMajMarkBreidenbaugh,BSC,USAFRMajKarlHaagsma,BSC,USAFR

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AprilJune200855referredtoastheSprayBranchofthe907thTacticalAirliftWing.In1986,theSprayBranchbegantotransitionfromC-123airplanestoC-130AairplanesanddevelopedthemodularaerialspraysystemforuseinC-130EandHairplanes.Theaerialspraymissionwasassignedtothe910thAirliftWingattheYoungstownAirReserveStation,Ohio,in1991.Nonmilitaryemergencyaerialsprayresponses(andthetargetedhealththreat)byAirForceaerialsprayassetsaspartoftheAirForceReserveareshowninTable1.TheAFASUtrainsforaprimarywartimemissionofprotectingdeployedtroopsfromarthropod-borneillnessbyparticipatinginongoingmosquitocontrolprogramsatdifferentlocationsthroughouttheUnitedStates.Bytraininginvariousgeographicregions,theAFASUgainsexperiencecontrollingdifferentvectorandnuisancespeciesunderdiversegeographicalandenvironmentalconditions.Thesamemeasuresareemployedforherbicideapplications.Somemissionsaredesignedforsoilsterilization,suchasattheUtahTestandTrainingRange,wherelargetargetsneedtoremainfreeofvegetationsothatunexplodedordinancecanbesafelyrecovered.Otherherbicidemissionsconcentrateonhabitatrestoration,byloweringthedominanceofinvasiveplantspecies,allowingnativeplantstorecoverandloweringthethreatofwildfires.TheAFASUhasbeeninvolvedwithprairierestorationontheSaylorCreekRange,Idaho,combatingthegrowthofcheatgrass(BromustectorumL.),andatSmokyHillAirNationalGuardRange,Kansas,forthecontrolofmuskthistle(CarduusnutansL.).Table2liststheAFASUscurrentstandingdomesticoperationalcommitmentsandthedatesofinceptionforeach.Asmentionedearlier,amodularaerialspraysystem(MASS)wasdevelopedforusewiththeC-130Hairplane.TheMASS,whichhasamaximum2,000-galloncapacityforliquidmaterials,canberolledonorofftheairplaneinapproximatelyone-halfhour.Functionalinavarietyofconfigurations,theMASSisusefulforsuchapplicationsasultralowvolumeadultmosquitosprays(adulticiding),mosquitoliquidlarvicidesprays,herbicideapplications,andoildispersantsforemergencycleanupofoilspills.Ultralowvolumesprayscreateanaerosolcloudofsmalldiscretedropletsthatdriftthroughtheair.Thistypeofapplicationisreferredtoasaspacespraysincethegoalistodriftdropletsthroughaparticularspaceresultingincontactwithflyinginsects.5Forthisreason,theflightperiodofthetargetpestsisoneofthemostimportantplanningfactorsformissionsusingtheultralowvolumeconfigurationtocontrolmosquitoesandnuisanceflies.8CurrentmethodologiesforAFASUmosquitoadulticidingusetheMASSwithboomsplacedthroughthefuselagedoors.Thoseboomsarefittedwithflatfannozzlespositionedperpendiculartotheslipstreamoftheaircraftformaximumshearandatomizationofthesprayedliquid.Thisisespeciallyimportantsincethediameterofadropletthateffectivelyadherestoamosquitois10mto25m.9Incontrasttospacesprayapplications,depositionspraymissionsproducelargedropswhichareintendedtodropquicklyontoasurface(eg,mosquitolarvicideorherbicideapplication).HURRICANESANDMOSQUITOESInresponsetorequestsfromstatepublichealthagencies,theAFASUhasbeentaskedtocontrolmosquitoesthreateninghumanhealthorcreatinganunacceptablenuisancelevelintheaftermathofhurricanes(seeTable1).10However,followingsomeYearLocationHealthThreatCoverage(acres) 1973 Panama Equineencephalitis 37,6001975GuamDenguefever157,530 1978 Azores Japanesebeetles 8,7001983MinnesotaEquineencephalitis525,000 1985 Idaho Grasshoppers 718,1001987PuertoRicoDenguefever177,000 1989 SouthCarolina HurricaneHugomosquitocontrol 855,5001992FloridaHurricaneAndrewmosquitocontrol279,170 1999 NorthCarolina,Virginia HurricaneFloydmosquitocontrol 1,700,0002005Louisiana,TexasHurricanesKatrinaandRitamosquitocontrol2,880,000Table1.NonmilitaryemergencydeploymentsbytheAFASUaftertransitiontotheUSAirForceReserve.

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56www.cs.amedd.army.mil/references_publications.aspxoftheseevents,federalauthorities,unfamiliarwithmosquitobiology,havequestionedthelocalpublichealthofficialsrequestsformosquitocontrol,apparentlyunawareofarelationshipbetweenhurricanesandincreasedmosquitoactivity.Sincethepresenceofmosquitoesfollowingstormsmaysurprisesome,perhapsthereisavalidquestion:dohurricanescreateabnormallylargemosquitopopulations?And,byextension,dohurricanesincreasetheriskofmosquito-borneillnessessuchasencephalitides,dengue,andmalaria?Sincemosquitolarvaedevelopinwater,itisnotdifficulttoextrapolatethatasignificantincreaseinpotentialbreedingsitesasaresultoffloodingfromhurricaneswouldleadtoasignificantincreaseinmosquitopopulations.Itisthispremisethatleadsmosquitocontrolpersonnelandvectorecologiststoanticipateincreasedmosquitonumbersfollowingmajorstorms.Logically,thepresenceofhighdensitiesofmosquitoesincreasesthepotentialfortransmissionofmosquito-bornedisease.Itis,however,importanttodefineparametersformakingsuchstatements.Accordingly,wemustidentifythemosquitospeciescapableofvectoringdiseaseanddetermineifthepathogenispresentintheresidentmosquitopopulationorenzootichosts.Thedestructivepowerofhurricanescreatesascenarioinwhichmosquitopopulationsareincreasingatthesametimemanypeoplearedisplacedorhavehadtheirprimaryshelterscompromised.Exposuretomosquitoesisincreasedbytheconcentrationofthosedisplacedbythestormintotemporaryshelters,andbytheiractivitiesastheysearchforfood,constructionmaterials,medicalcare,etc.Undersuchconditions,individualsmayfacemaximumexposuretonuisancemosquitobitesandmosquitovectors.MasonandCavalie11analyzedamalariaepidemicinHaitifollowingHurricaneFlorain1963,observinganexplosiveincreaseinmosquitobreedingbroughtonbyheavyrainfallandextensiveflooding.Inthiscase,theresearchersalsotiedanincreasedincidenceofmalariatoHurricaneFlorabecausealldiseasefactorswerepresent,includingaheavyreservoirofgametocytecarriers,mosquitoes,andanexposedpopulation(eg,peopledisplacedandresidualinsecticidetreatmentsnegatedbyhurricanedamage).Morerecently,Gagnonetal12reviewedtheincidenceofmalariainElNioyearswhichalwaysincludesignificantfloodingconditionsinSouthAmericaandfoundasignificantrelationshipbetweenfloodingandmalariaepidemicsinnorthernPeru.Bycontrast,inHonduras,HurricaneMitchkilled6,546peopleanddisplacedanother1.1millionfromexcessiverainfallandflooding.13Obviouslythispopulationwasveryexposedasaresultofthedisplacement,butCampanellaandTarantini14foundonlyasmallincreaseinmalariacasesbetweentimeperiodsprecedingthearrivalofHurricaneMitch(statisticallysignificantcomparedto1997butnotto1998).Likewise,OLearyetal15didnotfindanincreaseindengueinFederalEmergencyManagementAgency(FEMA)reliefworkersinPuertoRicoafterHurricaneGeorgesin1998.Theseresearchersrelatethat82%oftheworkersreportedmosquitobites,butunfortunatelytheydonotcommentontheoverallmosquitodensityduringthestudy.Expertsareoftenquestionedbythepopularpressandinsomecasesopinionsonthehurricane-mosquitodiseaseissuecandiffermarkedly.Forexample,theNewOrleansTimes-PicayunequotedtheStateEpidemiologistofLouisianaassayingthatheavyrainfallfromhurricaneKatrinaactuallykilledadultmosquitoes,washedawaylarvae,andkilledorTable2.CurrentAFASUdomesticoperationalcommitments.LocationorAgencyPurposeYearinitiatedLangleyAirForceBase,VAMosquitocontrol1973 MarineCorpsRecruitDepot,ParrisIsland,SC Bitingmidgesandmosquitocontrol 1983HillAirForceBase,UtahTestandTrainingRangeClearingbombingrangeundergrowth1983 USCoastGuard Oilspilldispersants 1992SmokyHillAirNationalGuardRange,KSMuskthistlecontrol1995 MountainHomeAirForceBase,ID Cheatgrasscontrol 2000GrandForksAirForceBase,NDMosquitocontrol2001 MinotAirForceBase,ND Mosquitocontrol 2005 TheUSAirForceAerialSprayUnit:AHistoryofLargeAreaDiseaseVectorControlOperations

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AprilJune200857THEARMYMEDICALDEPARTMENTJOURNALdispersedthebirdsthatcarryWestNilevirus.16Withoutquotingasource,in2006LauranNeergaardoftheAssociatedPressstatedsomewhatcontradictorilythatrecentresearchshows:Hurricanesdon'tspurWestNile[virusmosquitovectors].Instead,heavyrainstemporarilyflushoutthetinypoolswheremosquitoeshavelaideggs.YettheCDC[CentersforDiseaseControlandPrevention]fearsthatNewOrleansandtheGulfCoastareripeforasurgeinWestNilethissummerbecauseoftherubbleleftbyHurricaneKatrinalastyear,fullofwater-collectingcrevicesthatmakeperfectmosquitobreedinggrounds.17Othernewsarticlesmadecontrastingstatements.ThedirectoroftheUniversityofMinnesotaCenterforInfectiousDiseaseResearchandPolicywarnedthatfollowingHurricaneKatrina,ruralareascouldexpectdramaticincreasesinmosquitonumberswithin2weeks,especiallythoseareaswherethestormleftmanypoolsofstagnantwater.18Similarly,inOctober2005,theHoustonChronicle[online]reportsthat,accordingtoTexasA&MUniversityentomologyprofessorJimOlson,floodwatermosquitoestakeadvantageofadirecthitfromastorminuniqueways.Theyareabletohideingrassandavoidbeingblownawaybywind.Butwhenthestormsurgehits,theyrideitinlandlikesurfers,intonewterritory.Further,ProfessorOlsonsays,Thehurricaneactuallyconcentratesthem,itexacerbatestheproblem.19IncommentstoTheRockyMountainNewsinSeptember2005,DrJanetMcAllisteroftheCDCdescribedthemosquitoproblem2weeksafterHurricaneKatrinaashavingreachedbiblicalproportions.20However,intheonlinediscussionsontheProMEDwebsite,othercontributorsinthefieldsuggestedtheopposite.21Insummarizingtheaboveinformation,itappearsthatimmediatelyfollowingthelandfallofamajorhurricane,themosquitoproblemmayactuallydisappearorbeminimizedbyintensewind,rainfall,andflooding.However,itisgenerallyagreedthatadditionaldevelopmentalhabitatiscreatedbysuchstormsand,dependingonenvironmentalfactors(temperature,rainfall,contamination,topography,etc),largenumbersofvectorand/ornuisancebitingmosquitoescanbepresentinaperiodasshortas2weeks.22TheAmericanMosquitoControlAssociationandtheCDC,alongwithahostoffederal,state,andcountylevelpublichealthagencies,haveworkeddiligentlytoconvinceFEMAtoanticipatemajormosquitooutbreaksfollowinghurricanesandotherfloodproducingeventsandtodevelopstrategicresponsestosuchevents.DevelopingadialoguebetweenfederalandstatepublichealthagencieswasonereasonthatthevectorcontrolaspectsoftheresponsetoHurricaneKatrinawerequickanddecisive.HURRICANEKATRINAOnSeptember8,2005,theAFASUdeployedtoconductaerialsprayoperationsformosquitoandfilthflycontrolinsupportoftheFEMAHurricaneKatrinareliefeffortandwereofficiallyassignedtoJointTaskForceKatrinaonSeptember9,2005.Twosprayaircraft,aspareaircraft,and3crewssetupatDukeField,Florida,nearEglinAFBontheFloridapanhandle.DukeFieldwaschosenbecauseitwastheclosestfully-functioningmilitarybasewiththelogisticalcapabilityofsupportingtheC-130Hsprayaircraft.Atotalof53personnelwereinvolvedwiththeflying,entomology,maintenance,administrative,communicationandlifesupportissuesrelatingtotheAFASUresponse.TheextentofthedamagecausedbyHurricaneKatrinaiswellknown.23Highwindsdownedtreesanddestroyedhomes,whileheavyraincausedextensiveThepilotofanAirForceAerialSprayUnitC-130HairplanealignstheairplaneontothenextflightlineduringanaerialspraymissionoverNewOrleans,Louisiana,duringpost-KatrinaoperationsinSeptember2005.

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58www.cs.amedd.army.mil/references_publications.aspxflooding.Storm-inducedbreechesintheNewOrleansleveesystemresultedinthecatastrophicfloodingofapproximately80%ofthecity.PrehurricaneevacuationshadbeenincompleteinNewOrleansandsubsequentfloodingexacerbatedtheproblembysignificantlyincreasingthedifficultyofreliefefforts.InearlySeptember,thefull-scopeofdamageandlevelofhumansufferingwasstillunknown.Newsagenciesreportedpotentialhumanfatalitiesashighas10,000insideNewOrleans,incidentsofgunfireaimedatrescueaircraft,24andthatEPAwatertestsshowedE.colilevelswere10timesabovesafelevels.25Rapidmosquitoandflydevelopmentwasprojectedastemperaturesreached90Fduringtheday,andonlycooledintotheupper70s(F)atnight.Filthflies,whichhavethepotentialtodevelopquicklyinthetypeofhabitatcreatedinfloodedNewOrleans(eg,fecalcontamination,muck,trash,animalcarcasses)andmovebetweenunhygienicsubstratesandhumanfood,potentiallytransferringharmfulbacteriaintheprocess,wereconsideredtobetheimmediateinsectvectorpublichealththreatbypublichealthofficials.Apartfromfilthflies,anadditionalconcernforvectorecologistswasthatLouisianaalreadyhadabackgroundofWestNilevirus(WNV)circulatinginmosquitopoolsandbirds.ByAugust30,2005,40casesofWNVhadbeenreportedinLouisiana,including4deaths.ThatwasalreadymorecasesinLouisianathaninallof2004.26Byallaccounts,HurricaneKatrinacreatedenoughdamagetoexposethepopulationtopotentialvectorandnuisancemosquitofeeding.Inparticular,theabsenceofelectricity,physicaldamagetolivingstructures,andtheuseoftemporarysheltersby200,000displacedpeoplecombinedtomaketheseindividualsvulnerabletomosquitobitesandpotentialdiseasetransmission.Similarly,intensemosquitoexposuretorescue,cleanup,andutilityrepaircrews,aswellaslawenforcementpersonnelwasalsoprojected.Thus,mosquitoandflycontrolwasconsideredahighpriorityinthestrategytoprotectpublichealth.ThemajorcrisisofthestormwasthefloodingofNewOrleans.Therecoveryeffortincludedacombinedforcefromthemilitaryservices,aswellasotherfederal,state,andlocalagencies.ThemissionoftheAFASUwastoprovideastopgapmeasuretocontrolmosquitoesuntillocalmosquitocontrolprogramscouldresumeoperations.HurricaneKatrinahadcompletelydisablednormalmosquitocontroloperationswithintheentireregionsouthofLakePontchartrain.Thedamagerangedfromvariouslevelsofequipmentdamagetothedestructionofentirefacilities.Inoneunusualexample,spraytrucksfromOrleansParishwerepressedintoservicebyanArmyNationalGuardUnit.Further,employeesoflocalMosquitoControlDistricts(MCD)werethemselvesdisplacedbythestorm.AirForcesprayassetsprovidedaerialvectorcontroluntilMCDscouldregaintheirnormaloperationsorcontractscouldbeestablishedwithprivateapplicators.Anadditionalcomplicatingfactorfornonmilitaryaerialapplicatorswasthattheregionhadbeendesignatedasmilitarycontrolledairspace,makingsprayactivitiesbyprivateapplicatorsimpossibleattimes.TheperformanceofaerialsprayoperationsinandaroundNewOrleanswascomplicated.TheAFASUpreviouslyconductedsprayoperationsduringfederallydeclareddisastersbutthesituationinNewOrleanswasparticularlychallenging.Todeterminethevectorthreat,entomologistsfromtheLouisianaDepartmentofHealth,CDC,andAirForcevisitedareasinandaroundNewOrleans,conductedmosquitolandingcounts,surveysforfilthflies,anddirectlyconsultedwithbivouackingArmyandNavyPreventive AnAirForceAerialSprayUnitC-130HairplaneduringavectorcontrolmissionoverNewOrleans,Louisiana,September2005.TheUSAirForceAerialSprayUnit:AHistoryofLargeAreaDiseaseVectorControlOperations

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AprilJune200859THEARMYMEDICALDEPARTMENTJOURNALMedicineTroops.Thiswasthemosteffectivemeansofevaluatingtheinsectvectorpotentialbecausethestormhadseverelylimitedcommunicationbetweenorganizationsconductingvectorsurveillance.Telephoneandemailservicewaserraticandtroopscontinuedtomovearound.Insomecases,troopshaddeployedwithinsectsurveillanceequipmentbuthadnotimetoputittousebecauseofhigherprioritytasks.DrivinginNewOrleanswasdifficultsincemanyroadswerestillfloodedorobstructedbydebris.Also,militaryandpolicecheckpointswerefrequent.Thefewvehiclesontheroadswerelimitedtofirstrespondersmilitary,police,rescue,andutilityrepair.Thiswasactuallyfortunatesincefewintersectionshadfunctioningtrafficlightsandgeneraldisrepairexistedthroughoutthearea.Bydrivingtoforwardlocations,surveillancedatawasgatheredfromArmyandAirForcepersonnelfromtheLouisArmstrongAirportandNavypersonnelfromtheNavalAirStation.FLYCONTROLINNEWORLEANSTiminginsecticideapplicationswiththeperiodofmaximumexposureofthetargetpestisacriticalcomponentofanypestcontroloperation.Flycontrolbegan3hoursbeforesunsettocorrespondwiththediurnalactivityoffliesbutavoidthewarmestpartoftheday.Fuselageboomswereequippedwith6stainlesssteelflatfanTeeJetnozzles(size8008)(TeeJetTechnologies,Wheaton,Illinois.630-665-5000).DeliveredbyC-130Hairplanesfromaheightof150feetabovegroundlevelusing1,000footwidelaneseparations(swathwidth),theorganophosphateinsecticideDibromConcentrate(AMVACChemicalCorporation,4100EWashingtonBlvd,LosAngeles,California,90023)wasappliedatarateof1.0flozperacre,asrequestedbytheStateofLouisianaOfficeofPublicHealth.ApplicationsweremadeinOrleansParishon13and14September,andagainon21and27September,2005.Flypopulationsweremonitoredat6locationsinOrleansParishpriortotheaerialspraymissionon21Septemberbytheuseofstickyflypaperoutdoorsforapproximately24hours.Unfortunately,post-spraysurveillancewasnotpossiblebecausemilitarysupportforthisactivityhadbeenevacuatedinadvanceofHurricaneRita.Nonetheless,entomologistsonthegroundintheNewOrleansFrenchQuarterobservedheavymortalityinflies(sarcophagids,muscids,calliphorids,etc)within15minutesfollowingthesprayapplication.Fliesthatwererestingonthesidesofbuildingsorespeciallyintreesneargarbagepilesweremoreimpactedbytheapplicationthanthosefliesundercanopiesorcrawlingaroundunderthetrashbags/piles.Environmentalparameterswererecordedaspartlycloudyskies,lightsteadywind,3to6knotsfromthesouthandsouth-southwest,andtemperaturesrangingfrom88Fto82Fwithnoinversionlayers.Suchconditionsaregenerallyconsideredexcellentforanaerialapplication.Preseleyetal27foundlownumbersofmuscidfliesandmosquitoesinOrleansParishduringsamplestakenfrom16to18September,whichmaybetestamenttothesuccessofthesesprays.AerialapplicationsofDibromhavebeenutilizedagainstfliesfollowinghurricanessince1961.28AfterHurricaneCamille,Dubose29reportedmortalitiesincagedfliesbetween49%and95%,wherethelowerrangerepresentscagesinprotectedlocationsversushighermortalitiesfromcagesinexposedareas.ItisassumedsimilarmortalityratesoccurredduringtheseapplicationsinOrleansParish.MOSQUITOSPRAYSBEYONDNEWORLEANSMosquitosprayswerealsohighlysuccessfuloutsideofthegreaterNewOrleansarea.Inthesecases,Dibromwasusedat0.5to0.75floz/acre,dependingonmosquitopopulationdensities.Flatfannozzles(TeeJet8005)wereusedonairplanesflyingalaneseparationof2,500feet.Laneseparationwasdroppedto1,500feetinlowwindconditions(<5mph).Releasealtitudewas150feetabovegroundlevelforallapplications.InAcadiaParish(September29)theprimarypestmosquitoeswerePsorophoracolumbiae(Fabr.)andPs.ciliata(Dyar&Knab)asdeterminedbyAcadiaParishMosquitoControlpersonnelwhomeasuredlandingratesoftheseviciousbitersatanaverageof49perminute(range10to200,22sites).Windwasfromthenorthat6to8knots,temperaturewas84F,andrelativehumiditywas60%.Thesprayapplicationbegan2hourspriortosunset.Atotalof169,764acresweresprayed.An88%reductioninmosquitolandingrateswasobservedatthesesamelocationsthefollowingday.Thislevelofreductionwasconsideredtobeaborderlinesuccesssincelandingrateswerestillnoticeable.Inparishareasnotsprayed,averagelandingrateswerehigherthanthepreviousday(91perminute;range30to200,22sites).InresponsetoincreasingmosquitodensitiesandtheincompletecontrolfromtheSeptember29spraymission,the

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60www.cs.amedd.army.mil/references_publications.aspxapplicationratewasincreasedfrom0.5floz/acreto0.75floz/acreon30September.Environmentalconditionswerenearlythesameasthepreviousnight,northerlywindat4to6knots,temperature84F,relativehumidity60%.Again,sprayingcommenced2hourspriortosunsetandatotalof139,156acresweresprayed.ExcellentcontrolwasachievedfromtheSeptember30spraymission,andpost-applicationlandingcountswerereducedonaverageby99%(rangeofpercentreduction95%to100%).Inall,atotalof1,942,607acresinthefollowing12LouisianaparishesweresprayedforvectorandnuisancemosquitoesbytheAFASU:Increasingavailabilityofprivatecontractors,restorationofelectricalpower,andtheassumptionofnormalmosquitocontrolactivitiesbyMCDsledtheLouisianaStateOfficeofPublicHealthtoreleasetheAFASUonOctober10,2005.AdditionalAFASUspraymissionscontinuedinthestateofTexas,whereatotalof938,015acresweretreated.30AsshowninTable1,thecombinedtotalof2,880,622acreswasthelargestareatreatedsincetheAFASUwastransferredtotheAirForceReserves.CONCLUSIONTheAFASUresponsetoHurricanesKatrinaandRitaeffectivelyillustrateswhytheunitwasformedtoeffectivelyminimizetheoccurrenceofvectorsandnuisancepestsbytreatinglargeareaswheresuchpopulationsexist.Thisactivityalsodemonstratestheneedformilitaryaerialsprayassetsindomesticsituationswherelocalvectorcontrolagencieswereincapacitatedoroverwhelmed,anduseofcontractaerialsprayassetswasunfeasiblebecauseofsevereairspacerestrictions.Thisdeploymentofassetswasnotdoneinavoid.Withouttheassistanceofstateandfederalagenciesandtheirpersonnel,thedeploymentwouldhavebeenextremelydifficult,ifnotimpossible.Infact,MCDs,statehealthagencies,andaerialspraycontractorsborethebruntofpublichealthandvectorcontrolactivitiesfollowingtheAFASUsstanddownandredeployment.However,thiseventdemonstratestheAFASUsabilitytofillastopgaproleindomesticemergenciessuchasthatwhichfollowedHurricanesKatrinaandRita,anditsimportanceincivilianandmilitarycontingencies.ACKNOWLEDGEMENT TheauthorsthanktheAcadiaParishMosquitoControlagencywhichprovidedlandingcountsforAcadiaParishbeforeandafteraerialspraymissions,andCPTKurtKresta,MS,USA,forhiseffortsinthesamplingoffilthflydensities.WealsoextendaspecialthankyoutotheAFASUaircrewmembersandmaintenanceandsupportpersonnelfortheirunwaveringprofessionalismanddedicationtoensuringthesuccessoftheseveryimportantmissions.REFERENCES 1.HaysCW.TheUnitedStatesArmyandmalariacontrolinWorldWarII.Parassitologia.2000;42:47-52.2.ParrishDW,HodappCJ.BiologicalevaluationoftheC-47aerialspraysystemforadultmosquitocontrol.MosqNews.1962;22:36-37.3.KnappFW,PassBC.Low-volumeaerialspraysformosquitocontrol.MosqNews.1966;26:22-25.4.ServiceMW.2000.MedicalEntomologyforStudents,2ndEd.CambridgeUK:UniversityofCambridgePress.5.WorldHealthOrganization.Spacesprayapplicationofinsecticidesforvectorandpublichealthpestcontrol:Apractitionersguide.Geneva,Switzerland:WorldHealthOrganization;2003.6.DowellF.AnexaminationofUnitedStatesAirForceaerialsprayoperations.MosqNews.1965;25:209-216.7.ScheerCJ.AerialsprayingAirForcestyle.WorldAgricAviat.1975;2:12-13,23-30.8.WrightRE,KnightKL.EffectofenvironmentalfactorsonbitingactivityofAedesvexans(Meigen)andAedestrivittatus(Coquillett).MosqNews1966;26:565-578.9.MountGA.Optimumdropletsizeforadultmosquitocontrolwithspacespraysoraerosolsofinsecticides.MosqNews.1970;30:70-75.AcadiaAscensionBeauregardCalcasieuJeffersonOrleansPlaqueminesSaintBernardTangipahoaVermilionVernonWashingtonTheUSAirForceAerialSprayUnit:AHistoryofLargeAreaDiseaseVectorControlOperations

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AprilJune200861THEARMYMEDICALDEPARTMENTJOURNAL10.BreidenbaughM,OlsonS,SpearsB,TeigD.Emer-gencymosquitocontrolafterHurricaneFloyd.WingBeatsFlaMosqControlAssoc.2000;11(3):36-38.11.MasonJ,CavalieP.MalariaepidemicinHaitifollowingahurricane.JTropMedHygen.1965;14:533-539.12.GagnonAS,Smoyer-TomicKE,BushABG.TheElNiosouthernoscillationandmalariaepidemicsinSouthAmerica.IntJBiometeorol2002;46:8189.13.BalluzL,MollD,DiazMartinezMG,MeridaColindresJE,MalilayJ.EnvironmentalpesticideexposureinHondurasfollowingHurricaneMitch.BullWHO.2001;79:288-295.14.CampanellaN,TarantiniF.IncidenceofsomeinfectiousdiseasesinanareaofNicaraguaseriouslyaffectedbyHurricaneMitch.IgMod.2000;113:209-223.15.O'LearyDR,Rigau-PeRezJG,HayesEB,VorndamAV,ClarkGG,Gubler.DJ..AssessmentofDengueRiskinReliefWorkersinPuertoRicoafterHurricaneGeorges,1998.AmJTropMedHyg.2002;66:3539.16.UnitedPressInternational.HurricaneshelpstopWestNilevirus.Physorg.com[serialonline]January23,2006.Availableat:http://www.physorg.com/news10152.html.AccessedJuly2,2006.17.NeergaardL.WestNilebeginningitssummerassault.LasVegasSun.June26,2006.Availableat:http://www.lasvegassun.com/sunbin/stories/thrive/2006/jun/26/062602005.html.18.RoosR.HurricaneKatrinasparksfearsofdiseaseoutbreaks.CIDRAPNews[serialonline].September2,2005.Availableat:http://www.cidrap.umn.edu/cidrap/content/fs/food-disease/news/sep0205hurricane.html.AccessedJuly2,2006.19.HopperL.Rita'speskyoffspringarehereandthey'rehungry.2005.Availableat:http://www.chron.com/disp/story.mpl/special/05/rita/3384381.html.AccessedJuly2,2006.20.EricksonJ.Mosquitonumbersexplodeduetohurricaneflooding.RockyMountainNews.September13,2005.Availableat:http://www.promedmail.org/pls/promed/f?p=2400:1202:9066594965860822079::no::f2400_p1202_check_display,f2400_p1202_pub_mail_id:x,30431.21.ProMED-mail.Mosquitoes,posthurricane,USA(07).Archive20050918.2756:September18,2005.Availableat:http://www.promedmail.org/pls/promed/f?p=2400:1202:9066594965860822079::no::f2400_p1202_check_display,f2400_p1202_pub_mail_id:x,30431.Accessed8July2006.22.WatsonJT,GayerM,Connolly,MA.Epidemicsafternaturaldisasters.EmergingInfectDis.2007;13:1-5.23.ManuelJ.InKatrinaswake.EnvironHealthPerspect.2006;114:A32A39.24.AssociatedPress.NewOrleansmayor:10,000feareddead.Foxnews.com[serialonline].2005.Availableat:http://www.foxnews.com/story/0,2933,168489,00.html.AccessedJuly2,2006.25.FoxNews.Bacteriainwaters10xsafelevels.Foxnews.com[serialonline].2005.Availableat:http://www.foxnews.com/story/0,2933,168790,00.html.AccessedJuly2,2006.26.CentersforDiseaseControlandPrevention.Update:WestNilevirusactivityUnitedStates,2005.MMWR.2005;54:851-852.27.PresleySM,RainwaterTR,AustinGP,PlattSG,ZakJC,CobbGP,MarslandEJ,TianK,ZhangB,AndersonTA,etal.AssessmentofpathogensandtoxicantsinNewOrleans,LAfollowingHurricaneKatrina.JEnvironSciTech.2006;40:468-474.28.DavisNA,WhippAA,WarnerWW.ControlofhouseflieswithaerialsprayscontainingDibrom.Proceedingsofthe32ndAnnualMeetingoftheFloridaAnti-mosquitoAssociation.1961:31-33.29.DuboseW.Aerialspraytestswithcagedfilthflies.MosqNews.1970;30:266-267.30.BreidenbaughM,HaagsmaK,OlsonS,TeigD,SpearsB,McHughC,WalkerW,SandersD.AirForceaerialsprayoperationtocontroladultmos-quitoesfollowingHurricanesKatrinaandRita.WingBeatsFlaMosqControlAssoc.2006;17(2):7-15.AUTHORS MajBreidenbaughisChiefEntomologist,AirForceAerialSprayUnit,757AirliftSquadron,910thAirliftWing,USAFR,attheYoungstownAirReserveStation,Vienna,Ohio.MajHaagsmaisResearchEntomologist,AirForceAerialSprayUnit,757AirliftSquadron,910thAirliftWing,USAFR,attheYoungstownAirReserveStation,Vienna,Ohio.

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62www.cs.amedd.army.mil/references_publications.aspxPOLICYDEVELOPMENTNoise-inducedhearinglossappearsinliteratureasearlyasthe16thcenturywhenaFrenchsurgeonnamedAmbroisePardescribedacoustictraumaindetailwhenhewroteofthetreatmentofinjuriessustainedbyfirearms.1Evenso,theprotectionofhearingwouldnotbeaddressedfor3morecenturiesuntilthejetenginewasinvented,bringinglongoverdueattentionandaflurryofpolicydevelopmentaddressingthepreventionofhearingloss.In1976,theGeneralAccountingOffice,nowtheGovernmentAccountabilityOffice,issuedaninvestigativereport.2ThisreportidentifiedoverhalfofUSgovernmentemployees,includingtheDepartmentofDefense(DoD),asworkinginenvironmentswithinadequateproceduresforidentifyingandrectifyingoccupationalhealthhazards.Further,thereportrequestedthattheUSCongressamendtheOccupationalSafetyandHealthAct3tobringfederalagenciesundertheinspectioncontroloftheDepartmentofLabor.Asaresult,in1978,militaryaudiologistsandothergovernmentemployeesachievedstandardizationinmilitaryhearingconservationwiththepublicationofDoDInstruction(DODI)6055.12,4whichprovidesguidanceandrequirementsforhearingconservationimplementation.ToimplementDODI6055.12,theArmypublishedatechnicalbulletin(TBMED501,HearingConservation,nowdiscontinued)in1980.DODI6055.12wasupdatedin1987toimplementnewrequirementsestablishedbythe1983FederalNoiseAmendment.5Thenewpolicyidentifiedspecificroleresponsibilitieswithinahearingconservationprogramandtherebypavedthewayforthefirstenforceableregulationtobepublishedonthesubject.Thenew,andcurrent,implementingguidanceisDepartmentoftheArmyPamphlet40-501,HearingConservationProgram.6ThismultifacetedapproachtopreventionhasenjoyedmanyyearsofsuccessuntilOperationsEnduringFreedomandIraqiFreedom,asillustratedinFigure1.Thelargescalecombatoperationschallengedthisgarrison-orientedpreventionstrategy.Figure2demonstratesthatthemajorityofhearinglossintheArmyisconcentratedamongthoseSoldiersinvolvedincombat.DataaboutthepercentageofSoldierswhoreturnedfromacombatdeploymentwithsignificanthearingproblemsin2004arepresentedinTable1.Thesehearinglos-sesarethedirectresultoftheirnoiseexposure,andemphasizetheimportanceofhearingprotectionforcom-batandcombattraining.AnnualdatafromtheDepartmentofVeteransAffairs(VA)evidencedtheimmediacyforimplementingchangebyshowinghearingasaprimarydisability.12-14In2006,theVAawarded55,864newcasesforhearingEvolutionoftheArmyHearingProgramMAJD.ScottMcIlwain,MS,USACPTKaraCave,MS,USACOLKathyGates,MS,USACOL(Ret)DonCiliax,MS,USAFigure1.PercentageofUSArmyForcesCommandSoldiersclassifiedwithH3hearingprofile*orgreater,displayedbyyeartodemonstratethemarkedincreaseshownsincethebeginningsofOperationsEnduringFreedom(October2001)andIraqiFreedom(March2003).*H3hearingprofileisdefinedbytheUSArmyStandardsofMedicalFitness7asspeechreceptionthresholdinbestearnotgreaterthan30dBHL,measuredwithorwithouthearingaid;oracuteorchroniceardisease.Chartisacompilationofdatafrom3studies.8-10(Source:http://chppm-www.apgea.army.mil/hcp//figurestables.aspx)andtheDefenseOccupationalandEnvironmentalHealthReadinessSystemDataRepository,ComprehensiveHearingThresholdDatabasefortheDeptofDefense,2008.(Source://doehrswww.apgea.army.mil/doehrsdr/). 0102030405060 34.3 16.6 16.2 51.8 1974 1989 1994 2007 P e r c e n t a g e

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AprilJune200863lossalone.BetweenthestartsofOperationsEnduringFreedomandIraqiFreedom,compensationpaymentsforhearinglossincreasedby319%.HearinglossisthesecondmostcommonnewdisabilityawardbytheVA,surpassedonlybytinnitus.In2007,hearinglosscompensationreachedover1billiondollarsforapredominantlypreventableinjury.Thesefiguresdonotaccountforservicememberswhoremainonactivedutywithhearinglossorthosewhomaylosehearinginthefutureasaresultofcurrenthazardousnoiseexposure.Furthermore,thedatapresentedareforprimarydisabilityonlyanddonotincludeVeteranswhohaveanotherprimarydisabilityrating,suchasanamputatedlimb,incombinationwithhearinglossortinnitusasasecondarydisability.ACCEPTINGCHANGEWhetherinpeacetimeorwartime,hazardousnoiseexistsasoneoftheprimaryoccupationalhazardsintheArmy.Theriskofnoise-inducedhearinglossinSoldiershasreachedthehighestrateinover30years.Thistrendresultedfromcurrentcombatoperations,increasednumbersofcombatarmsSoldiers,extendedperiodsofweaponstraining,anddeploymentofnewandmorepowerfulnoisesourcesfromweaponssystems,vehicles,andaircraft.USforcesinIraqandAfghanistanexperiencedasubstantialnumberofblastinjuriesfromimprovisedexplosivedevices,rocket-propelledgrenades,andmortarrounds.ThesetypesofexplosionsremaintheTable1.Clinicallydiagnosednoise-inducedhearinglossincidenceratesamongSoldiers,April1,2003,throughMarch31,2004.*ConditionDiagnosedPostdeploymentRelatedDiagnosis(n=806)NondeploymentRelatedDiagnosis(n=141,050)AcoustictraumaPermanentthresholdshiftTinnitusEardrumperforationH3orH4hearingprofile4523624813127(5.6%)(29.3%)(30.8%)(1.6%)(15.8%)786392101883140(0.1%)(0.5%)(1.5%)(0.1%)(2.2%)Anyoftheabove553(68.6%)5668(4.0%)*DataarefromHelferetal.11DiagnosesascodedinaccordancewiththeInternationalClassificationofDiseases,9thRevision,ClinicalModification(USPublicHealthService). CENTCOM0.40%FORSCOM*61.57%CENTCOM1.94%FORSCOM*51.98% 2 0 0 7 2 0 0 6Figure2.PercentageofSoldiersinFORSCOM*andCENTCOMwhotestedatH2andH3orgreaterhearingthresholdlevelsin2006and2007.**Overall,amuchlargerpercentageofFORSCOMSoldiersareinvolvedincombatoperations,andthecorrespondingimpactonhearinglossisclearlyreflectedinthedata.*ArmyForcesCommandArmyCentralCommandAudiometeraveragelevelforeachearat500,1000,2000Hz,ornotmorethan30dB,withnoindividuallevelgreaterthan35dBatthesefrequencies,andlevelnotmorethan55dBat4000Hz;oraudiometerlevel30dBat500Hz,25dBat1000and2000Hz,and35dBat4000Hzinbetterear.(Poorerearmaybedeaf).H3hearingprofileisdefinedbytheUSArmyStandardsofMedicalFitness7asspeechreceptionthresholdinbestearnotgreaterthan30dBHL,measuredwithorwithouthearingaid;oracuteorchroniceardisease.**Chartisacompilationofdatafrom3studies.8-10(Source:http://chppm-www.apgea.army.mil/hcp//figurestables.aspx)andtheDefenseOccupationalandEnvironmentalHealthReadinessSystemDataRepository,ComprehensiveHearingThresholdDatabasefortheDeptofDefense,2008.(Source://doehrswww.apgea.army.mil/doehrsdr/).

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64www.cs.amedd.army.mil/references_publications.aspxsinglelargestcauseofinjuryfromOperationIraqiFreedomandcomprise47%ofallmedicalevacuations.15Asaresult,developmentsinprotectingSoldiersfromthesetypesofhazardsareparamount.TheCombatArmsEarplug(CAE)isanonlinearearplugthatallowseffectivecommunicationandsituationalawarenesswhileprovidingprotectionfromhazardousimpulsenoises.IntroducedtothemilitarybythestartofOperationEnduringFreedom,Soldiersshunnedthemforoperationaluse.Astonishingly,theywerealsoconsideredcostprohibitivebytheunitsatapproximately$6perpair.Withunitsstrengthsdecreasingbecauseofhearingloss,in2004themilitarybeganissuingCAEstoalldeployingSoldiersandMarines.Infact,theMarineCorpswassoconvincedoftheconceptthattheyorderedover20,000pairsin2004,temporarilydepletingtheentirenationalstockofCAEs.AnecdotalinformationfromaudiologistswhoservedinIraqindicatedthatnoSoldierseenatacombatsupporthospitalwhoreportedthatheorshewaswearingtheCAEwhenexposedtoanexplosionhadrupturedeardrums.16TheCAEisnowarapidfieldingissueitemfordeployingSoldiers.TheCAEallowsmostspeechinformationtopassthroughwithminimalattenuation,whileprotectingagainstnoiseassociatedwithcombatevents.TheCAEwillsoonbecomeastandardissueitemforallinitialentrySoldiers,allowingthemtotrainwiththeCAEpriortousingthemincombat.15ArmyAudiologistshavebeenservingwithcombatsupporthospitalsinIraqsinceJanuary2004.Providingthesereactiveservicesintheaterwaslogical,buttheconceptwasnotwhollysoundbecauseitneglectedtheneedforpreventionandmaintenanceof TheCombatArmsEarplug(ImagecourtesyofAearoTechnologies,5457W.79thStreet,Indianapolis,IN46268) TacticalCommunicationandProtectiveSystemTheobstacleofprotectinghearingwhileenhancingaSoldierscommunicationabilityandsituationalawarenessisbeingaddressedbyanewgenerationofhearingprotection.Thisnewcategoryofequipmentisknownasthetacticalcommunicationsandprotectivesystem(TCAPS).TCAPSintroducedanewcategoryofelectronichearingprotectionthatutilizesactivenoisereductiontosoftennoise,thusenhancingspeechdiscrimination,whileatthesametimeprovidinganoisereductionrateofupto40dB.Inadditiontobeinglightandrugged,TCAPSdevicesprovideprotectionandallowSoldierstomonitorenvironmentalsounds,communicate,accuratelygaugeauditorydistance,andlocalizesoundsourceswithouthindrance.Furthermore,someofthesedevicesallowprocessingofmilitaryspecificradioconnectionswithoutsignalinterruptionwhilereducingenvironmentalsounds.QUIETPRO(NacreUSInc,106BudPlace,Aberdeen,NorthCarolina28375),oneoftheTCAPSdevices,isarapidequippingforceitem.Itallowsbothhearingenhancementandprotection.TheresponsefromSoldiershasbeenextremelyfavorable,infact,anecdotalinformationindicatesthattheydonotwanttodeploywithoutthem.Also,Soldiersofthe4thInfantryDivision,3rdBrigadeCombatTeamarereceivingQUIETPROdevicestouseduringtheirimpendingOperationIraqiFreedomdeployment.Audiologistsareworkingcloselywiththe3rdBCTleadershiptoensurethatthedevicesareproperlyfittedtoSoldiers,andtheyaretrainedonthedevices.Inaddition,allSoldiersareprovidedpredeploymenthearingservices,whichincludeapredeploymentaudiogram,earplugfitting,andahealtheducationbriefing.QuietproTCAPSDevice(PhotocourtesyofNacreUS,Inc.) EvolutionoftheArmyHearingProgram

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AprilJune200865THEARMYMEDICALDEPARTMENTJOURNALSoldierhearingreadinesswhileinaforwarddeployedenvironment.Theparadigmofwhatcomposedacomprehensivehearingconservationprograminthepasthasshifted,andnowconsiderstheSoldiersenvironmentonthebattlefield.Operationalhazardousnoisesituationsthatinvolvedlargemilitary-uniqueequipment,lengthyworkdays,andimmatureinfrastructureofbasecampsareaddressed.UrbanterrainsuchasthestreetsofBaghdadisaparticularhazardforSoldiersbecauseitiswroughtwithobstaclessuchasbuildings,alleyways,andditches.Tocompoundtheimportanceofgoodhearing,civilianinhabitantsmustbedistinguishedfromactualcombatantsinanoftenchaoticenvironment.AstudywasconductedbytheUSArmyHumanEngineeringLaboratoryin1990toinvestigatetheeffectsofcommunicationsonperformance.17Theexperiment,involving30experiencedtankcrews,requiredcrewstoconductgunneryscenariosundercommunicationconditionsrangingfromverygoodtoextremelypoor.Performancemeasureswererecordedindifferentlevelsofspeechintelligibilityforeachscenario,basedonthemodifiedrhymetest(astandardizedintelligibilitytest).Fivelevelsofspeechintelligibilitywereused:100%,75%,50%,25%,and0%intelligible.Thespecificmeasuresusedtoevaluateperformanceasafunctionofspeechintelligibilityweremissiontime,missioncompletion,missionerrors,andgunneraccuracy.Thescenariosconsistedof10missions,eachrequiringthecommandertoinstructthegunnertoshootatupto3targets(21targetsperscenario).Fourtargets(tank,truck,helicopter,ortroops)appearedduringeachmission.Asisthestandardoperatingprocedureforarmoroperations,itwasthecommanderstasktoinstructthegunnertoshootattheappropriatetargetwiththeappropriateweapon.Theresults,displayedinTable2,arecompellingfortheargumentthatthemultidimensionalsenseofhearingprovidesanindispensableamountofinformationandcouldmeanthedifferencebetweenlifeanddeathonthebattlefield.THEARMYHEARINGPROGRAMTheArmyhadtodevelopthemeanstopreventnoise-inducedhearinglossinSoldierswhileensuringtheirmaximumcombateffectivenessintrainingandduringdeployments.Asaresult,acontemporarymodelcalledtheArmyHearingProgram(AHP)wasestablished.TheAHPprovidespreventionservicesinamorefluidenvironmentthanthatexperiencedingarrison.AstheArmytransforms,theAHPwillbettermeettheneedsofArmyciviliansandSoldiersinallenvironments,especiallythosewherethetraditionalhearingconservationapproachdoesnot.TheAHP,anoperationalapproach,provideshearingservicestoSoldiersintheirtrainingandoperationalenvironments.TheAHPconsistsof4majorelements:hearingreadiness,clinicalhearingservices,operationalhearingservices,andhearingconservation.ThiscombinationofservicespromotesandincreasesSoldierawarenessofhearing,andtheimportanceofmaintainingnormalhearingforgoodsituationalawarenessandvoicecommunicationinanyenvironment,includingcombat.Duetocurrentcombatoperations,theriskofSoldiersincurringnoise-inducedhearinglossisgreaternowthanithasbeenin30years.HazardousnoiseisoneoftheprimaryoccupationalhazardsintheArmy.Asaresult,AMEDDaddedauthorizationsfor10badlyneededArmyAudiologistsin2007.ThesepositionswillhaveapositiveimpactontheArmyHearingProgram,butwillstillplacetheinventoryatapointthatisone-thirdlowerthanitwasin1990.HearingservicescontinueinthecombatsupporthospitalinsupportofOperationIraqiFreedom.Theprevalenceofacoustictraumaishighinthecombattheater,andcommanderscannotaffordtoloseSoldierstoamedicalevacuationforseveralweekstodeterminetheirhearingstatus.Inordertoensurehearing-injuredSoldiersareprovidedimmediatecare,hearingsiteshavebeenestablishedatallmajorforwardoperatingbasesinIraq.SoldiersreceiveimmediatehearingcareFunctionGoodWordIntelligibilityPoorWordIntelligibilityTimeRequiredtoIdentifyTarget40Seconds90SecondsIncorrectCommandHeard1%37%CorrectTargetIdentification98%68%CorrectTargetsEngaged94%41%IncorrectTargetEngaged0%8% Table2.ResultsoftheUSArmyHumanEngineeringLaboratorystudyofcommunicationonperformanceoftankcrewsundersimulatedbattlefieldconditions(1990).DatafromGarintherandPeters.16

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66www.cs.amedd.army.mil/references_publications.aspxandfollow-upservicesin-theater,andarequicklyreturnedtoduty.CONCLUSIONArmy-wideimplementationoftheAHPrequiresadditionalhearingresourcestoensurebothclinicalandnonclinicalhearingservicesareprovidedtoSoldiers.InSeptember2006,hearingreadinesswasincludedintheReadinessModuleoftheMedicalProtectionSystem.Commandersandmedicalleaderscannowmonitorindividualandunitcompliance.HearingreadinesscomplianceforactivedutySoldiersiscurrently74%,a15%increasesinceSeptember2006.15FundingisprojectedtofullyimplementAHPtobringhearingconservationintothe21stcentury,meetingthechallengesoftodaysbattlefieldandthatoftheforeseeablefuture.TheArmywillnolongeraccepthearinglossasaninevitablebyproductofmilitaryservice.REFERENCES 1.NulandS.Doctors:TheBiographyofMedicine.NewYork;VintageBooks:1988.2.USGeneralAccountingOffice.HazardousWorkingConditionsinSevenFederalAgencies.Washington,DC:USGeneralAccountingOffice;1976;PublicationHRD-76-144:1-104.3.OccupationalSafetyandHealthActof1970,PubLNo.91-596,84STAT.1590(1970).4.DepartmentofDefenseInstruction6055.12:DoDHearingConservationProgram(HCP).Washington,DC:USDeptofDefense;March5,2004.5.OccupationalNoiseExposure;HearingConservationAmendment;FinalRule.Fed.Reg.48:9738-9785,Mar.8,1983.6.DAPamphlet40-501:HearingConservationProgram.Washington,DC:USDeptoftheArmy;December10,1998.7.ArmyRegulation40-501:StandardsofMedicalFitness.Washington,DC:USDeptoftheArmy;December14,2007:80.8.WaldenBB,ProsekRA,WorthingtonDW.ThePrevalenceofHearingLossWithinSelectedU.S.ArmyBranches.Washington,DC:USArmyMedicalResearchandDevelopmentCommand,USDeptoftheArmy;August31,1975:1-49.9.OhlinD,AspinallKB,MonkWH.HearingconservationintheU.S.Army.ArmyMedDeptJ.Fall1994:38-42.10.OhlinD.U.S.Armyhearingconservationprogramyieldscostavoidancefromreducedveteranshearinglossdisability.USACHPPMToday.1995;2(2).11.HelferT,JordanN,LeeR.PostdeploymenthearinglossinUSArmySoldiersseenataudiologyclinicsfromApril1,2003,throughMarch31,2004.AmJAudiol.2005;14(2):161-168.12.USArmyCenterforHealthPromotionandPreventiveMedicine.Veteranscompensationreports.2007.Availableat:http://chppm-www.apgea.army.mil/hcp//resources/2006_veterans_compensationchart.ppt.AccessedSeptember6,2007.13.USArmyCenterforHealthPromotionandPreventiveMedicine.VeteransAdministrationDisabilityReport.2007.Availableat:http://chppm-www.apgea.army.mil/hcp//resources/2006_vadisabilityReport.ppt.AccessedSeptember6,2007.14.USArmyCenterforHealthPromotionandPreventiveMedicine.Costeffectivenessofhearingconservationprograms.2007.Availableat:http://chppm-www.apgea.army.mil/hcp//costeffective.aspx.AccessedSeptember6,2007.15.GatesK.Operationalhearingservices.MilitaryAudiologyShortCoursepresentedat:AnnualMeetingofMilitaryAudiologyAssociation;April18,2007;Denver,CO.16.McIlwainDS.AudiologyinOperationIraqiFreedom.AudiolToday.2004;16(5):24-25.17.GarintherGR,PetersLJ.Impactofcommunicationsonarmorcrewperformance.ArmyResDevAcquisBull.January-February1990:1-5.AUTHORS MAJMcIlwainisaninstructorandcoursewriterintheDepartmentofPreventiveHealthServicesattheArmyMedicalDepartmentCenterandSchool,FortSamHouston,Texas.CPTCaveisChiefoftheFortBlissHearingProgramattheWilliamBeaumontArmyMedicalCenter,FortBliss,Texas.COLGatesistheAudiologyandHearingProgramConsultanttoTheArmySurgeonGeneral.SheisalsotheProponencyOfficerforPreventiveMedicine,OfficeofTheSurgeonGeneral,FallsChurch,Virginia.COL(Ret)CiliaxisanArmyHearingProgramConsultantattheCenterforHealthPromotionandPreventiveMedicine,AberdeenProvingGround,Maryland.EvolutionoftheArmyHearingProgram

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AprilJune200867Animportantaspectofvector-bornediseasepreventionisanunderstandingofhowtodefeatthehostreservoirpathogen-vectorcyclethroughvectorsurveillance.Surveillancemayleadtoneworimprovedvectoridentificationinformation,revisedvectorchecklistsanddistributions,newinformationaboutvectorbionomics,orusefulaspectsofhost-reservoir-pathogen-vectorinteractions.Overthepastdecade,ArmyentomologistsandtheirKoreancollaboratorshavesignificantlyincreasedsurveillancestudiestoupdateknowledgeandanswerquestionsaboutvector-bornediseaseimpactsonpotentialmilitaryoperationsintheRepublicofKorea(ROK).Thestudieshaveattemptedtoincreaseourknowledgeofpathogen-vector-host-reservoirrelationships,primarilyintermsofvectoridentificationandbionomics,hostbehavior,geographicalandseasonaldistributions,andpotentialcontrolormitigationsolutions.Vectorsurveillanceisfurtheraugmentedbyhumanepidemiologicalinvestigationsthatidentifyhumanpopulationsatrisk,anddiseasedistributionsthatcanbecorrelatedwithrelativevectorimportance.Country-specificknowledgewasacquiredthroughthesestudiestoexplainthehumansideofdiseaseacquisition.Portionsofthisarticlecondensetheresultsofselectedvectorsurveillanceprogramsofthe18thMedicalCommand(MEDCOM),Yongsan,Korea,but,moreimportantly,focusonunderstandingKorea-specificdiseaseissues.MALARIADuringtheKoreanWar,annualmalariaratesrangedfrom8.3to39.2per1,000Soldiers.1In1979,afteryearsoferadicationefforts,theWorldHealthOrganization(WHO)declaredtheROKtobemalariafree.2However,in1993,aKoreansoldierbasednearthedemilitarizedzone(DMZ)whohadnorecenttravelhistorywasdiagnosedwithvivaxmalaria.3ThiscasewasidentifiedasautochthonoustransmissionthatrapidlyspreadthroughouttheROKtroopsstationedalongtheDMZ,andsubsequentlytolocalciviliancommunities.BasedonWHOreports,NorthKoreaexperiencedasimilarresurgenceofmalaria,especiallyalongtheDMZ.WhileitwasthoughtmalariaintheROKoriginatedfromNorthKorea,itsoonbecameevidentthatmalariawasagainendemicintheROK.3-5TheTablepresentsthenumberofmalariacasesreportedannuallyintheROKsince1993.WhilemalariaremainsconcentratedalongtheDMZinnorthernGyeonggiProvince,otherareasoftheROKarebeingaffectedasROKveteransreturntotheirhomesanddevelopmalariaresultingfromlatentliverstages.6-8Consequently,malariaspreadsthroughoutthepeninsula.Insimilarfashion,KoreansvisitingnorthernGyeonggiProvincemayacquirethedisease,andthenreturntotheirhome,elsewhereinKorea,afterwhichthediseaseisexpressed.6-8Iftheinfectiveperson(demonstratingfeversandchills)waitsseveraldaysbeforeseekingmedicalattentionandisfeduponbyvectormosquitoes,afocalpointformalariamayhavebeencreated,anditmayormaynotsurviveforsuccessivetransmissionorseasons.Inordertodeterminewheremalariaoccurs,especiallyinmilitaryortransientpopulations,onemustdeterminewheretheinfectivemosquitofedupontheaffectedperson.Sinceittakesfrom12daystoayearforvivaxmalariatoexpressdisease(bloodstageparasites),thelocationsofwherethediseasewasexpressedandwhereitwasacquiredareoftencompletelydifferent,especiallyamongSoldierswhotrainalongtheDMZ,thenreturntotheirhomebaseorareredeployedtotheUSorothercountries.Therefore,detailedpatientinterviewsbypreventivemedicinepersonneltrainedinconductingepidemiologicalinvestigations/interviewsareessentialforqualitydatacollectionanddeterminationofthesiteoftransmission/infection.Toachievethis,selectedpersonnelintheForceHealthProtectionstaff,18thMEDCOM,conductinterviewsandrecordandanalyzePerspectivesofMalariaandJapaneseEncephalitisintheRepublicofKoreaLTCWilliamJ.Sames,MS,USAHeung-ChulKim,PhDCOL(Ret)TerryA.Klein,MS,USA

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68www.cs.amedd.army.mil/references_publications.aspxthesedataforallUSmilitarymalariacasesdiagnosedintheROK.Personnelwhodonotregularlyworkmalariaissuesmayassumetheareaofdiseaseexpressioniswherethediseasewasacquired.Thishasleadtotheimplementationofcorrectiveactionsinthewrongarea.Forexample,vectorcontrolactionsmaybeimplementedinareaswithfewvectors,andwarningsmaybegiventobasesorcommunitieswheremalariaisverylowrisk.Inotherinstances,unitleadersmaythinkthattheyhadasuccessfultrainingeventbecausenoonecontractedmalariaduringtheevent.However,theydonotassociatefuturediseaseexpressionastheresultofinadequateprotection,whichmanytimescanbetracedbacktothelackofcommandemphasisonpersonalprotectivemeasures(PPM)duringtheirtrainingevent.Thedelayintheonsetofsymptomsblursthedirectcause-consequencerelationship.Therefore,mostpeoplefailtoassociatetheirfailuresinprotectiveactionswiththeconsequencesofcontractingthedisease.Anophelesmosquitoesoverwinteraseggsornulliparousfemales(unfedfemaleswithouteggs),whichdonotbecomeinfecteduntiltheyfeedonapersonwithcirculatingparasites.Therefore,theannualvivaxmalariacycleisonlymaintainedbyapooloflatentmalariacasesandasymptomaticcarriers.AsthetemperaturewarmsinlateApriltoearlyMay,theoverwinteringfemalemosquitotakesabloodmealandlayseggs3to5dayslaterwithresultantincreasingvectorpopulations.Thesenoninfectedvectormosquitoesbitepersonsexpressingthelatentformofmalaria,oruntreatedindividualswhonolongerdemonstratesymptomsbutharborinfectiveparasites,whichinturninfectthenewuninfectedvectors.Thevectorpopulationcontinuestoincreasethroughoutthesummerandinteractionswithinfectivereservoirsandsusceptiblehostsassurethatsomeoftheparasiteswillbeacquiredandtransmittedbythevector.InruralareasalongtheDMZ,theprobabilityofacquiringmalariainAprilorMayislow,butsteadilyincreaseswithpeaktransmissiontimesoccurringinlateJulyandthroughoutAugust.Duringthepeakperiod,thevectorpopulationisgenerallyatitshighest.Becausetherehasbeensufficienttimeduringthisperiodforvector-reservoirinteraction,itistheoldermosquitothatisthedangerousmosquito(theperiodfromingestionoftheparasitetotransmissionisaminimumof9daysatoptimaltemperatures).Drainageofthericepaddiesforharvestmarksthedownturnofmalariavectorpopulationsandresultsinasignificantdecreaseinthenumberofmalariacases,whichtypicallystoppresentinginOctoberorearlyNovember.Anumberoffactors,includingdroughts(reductionofbreedingsites),heavyrainfrommonsoonsandcyclones(mosquitoeswasheddownstreamandolderadultmosquitoeskilled),pesticide/herbicideusageinthericepaddies(overhanginggrassesalongthebanksprovidehabitat)affectpopulationlevelsandthemeanNumberofPlasmodiumvivaxmalariacasesreportedintheRepublicofKorea(ROK)byyearsince1993.YearUSForcesKoreaROKMilitaryROKVeteransROKCiviliansTotal199311002 1994 3 18 1 2 241995188127108 1996 14 285 25 46 3701997331,1562073611,757 1998 42 1,657 1,127 1,148 3,9741999581,0849961,5413,679 2000 48 1,289 1,273 1,580 4,1902001306737481,0672,518 2002 48 406 472 885 1,8112003302732745601,137 2004 22 158 244 424 8482005172333227691,341 2006 24 311 432 1,278 2,0452007344474621,2712,214 Total 405* 8,079 6,595 10,939 26,018*Distribution:USmilitary-361;KoreanArmyaugmenteestotheUSArmy-43;DoDcivilian-1Sourcesofdata:KoreaCenterforDiseaseControlandPrevention,Seoul,ROK;ForceHealthProtection,18thMedicalCommand,YongsanGarrison,ROK. PerspectivesofMalariaandJapaneseEncephalitisintheRepublicofKorea

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AprilJune200869THEARMYMEDICALDEPARTMENTJOURNALageofthepopulationthatdirectlyimpactsontransmissionlevels.Asmanyoftheseconditionsarevariable,theyaffectthenumberofmalariacasesforanygivenyear.Forexample,averylateautumnduring2006resultedinaspikeofmalariacasesattheendofthemalariaseasonandcontributedtoanincreasednumberoflatentcasesthefollowingyear.OnlycertainAnophelesspeciesvectormalaria.Theyfeedsometimebetweenduskanddawn,andareoftenclassifiedasprimaryorsecondaryvectorsdependingontheirrelativesusceptibilitytoacquiresalivaryglandinfectionsandinteractionwithhumanhosts,assomearezoophilicandprefertofeedonlargeanimalssuchascows.9,10Until2005,An.sinensiswasconsideredtheprimarymalariavectorinKorea,anditwasthoughttobedistinguishedfromotherAnophelesspeciesbymorphologicalcharacters.In1999,whilerearingprogenybroodsfortheWalterReedBiosystematicsUnit(WRBU),twooftheauthors,COLKleinandDrKim,discoveredthatmembersofonesampledemonstratedcharacteristicsof2ormorespecies.Subsequently,moreprogenybroodsfromwild-caughtbloodfedfemaleswerereared,andaselectedfragmentoftheITS2genewassequencedbypolymerasechainreactionbyaWRBUteamandaresearcherfromtheUSArmyMedicalResearchInstituteforInfectiousDiseasetodeterminespeciesandsubsequentlydetermineifmorphologicalcharacterscouldbeappliedfortheiridentification.In2005,theseteamsofArmyandKoreanentomologistsdeterminedthatAnophelessinensisandcloselyrelatedspeciesconsistedofatleast5species:An.sinensis,An.pullus,An.lesteri,plus2newspecies:An.belenrae,andAn.kleini,andfurtherdemonstratedthatthesespeciescouldnotbereliablyidentifiedbymorphologicalcharacters.11Thesesameentomologists,workingwiththeArmedForcesResearchInstituteofMedicalSciencesandtheKoreaNationalInstituteofHealth(KNIH),implicatedAn.pullusandAn.kleiniastheprimaryvectorsofmalaria,withAn.sinensishavingalesserrole.10Therefore,areaswithrelativelylargepopulationsofAn.pullusandAn.kleinishouldcorrelatewithareasforthehighestriskofmalaria.Preliminaryinvestigations,human-basedsurveillance,andlarvalandadultsurveillancestudiessuggestthatthereisavalidcorrelationbetweenthenumbersofmalariacasesandtheseprimaryvectorpopulations.Thesestudiesarealsoworkingtodetermineifthereisaseparationofthelarvalhabitatbetweenthesespecies,socontroleffortscanfocusonselectedhabitatsofgreaterimportanceratherthanonlargescaleareas,whichdonotsupportlargevectorpopulations.*JAPANESEENCEPHALITISJapaneseencephalitis(JE)isaviralmosquito-bornediseasethatcanaffectthehumancentralnervoussystem,andmaybefatalorleavepeoplewithmildtoseverebraindamage(neurologicaldeficiencies).ItisvectoredbyCulextritaeniorhynchusinKoreaandposesagreaterthreatsouthofSeoulwhereverylargevectorpopulationsoccur.Largewaterbirdsaretheprimaryreservoirandswinefunctionasamplifyinghosts.Humansareconsideredtobedead-endhostsastheyrarelydevelopsufficientviremiatoinfectmosquitoes.Thediseaseisprevalentwherewetlandricefarmingoccurs,withpopulationdensitiesofvectormosquitoespeakingneartheendofsummerandearlyfall(AugusttoearlyOctober).JapaneseencephalitiswasfirstidentifiedfromanAmericanSoldieratInchonin1946.12In1949,JEbecameanotifiablediseaseand5616casesresultingin2729deaths(49%)werereported.After1950,outbreaksofseveralthousandcaseswerereportedperiodicallyevery2to3years.Thelargestoutbreakoccurredin1958with6,897cases.Since1958,therewerebetween2000to3000casesreportedannuallyuntil1968.13Inthemidtolate1960s,theKoreangovernmentinstitutedamassiveJEimmunizationprogramforschool-agedchildrenwhichsignificantlychangedtheepidemiologyofJEinKorea,butnotthethreat.Sincetheinceptionoftheprogram,thenumberofJEcasesdroppedsignificantly,andformostyearsonlyafewsporadiccases(0to7casesannually)haveoccurredoverthepastdecade.Inadditiontotheimmunizationprogram,avastimprovementoftheenvironment,sanitation,andahigherstandardoflivingcontributedtothereductionofJEcases.Therelativeproportionofsymptomatictoasymptomatic(ormildunreported)casesis1/25to1/1000(andperhapslessinhealthyyoungmen),while *Seerelatedarticleonpage46.

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70www.cs.amedd.army.mil/references_publications.aspxJEinfectionsmayresultinseveremorbiditywith10%to30%mortalityamongthosethatdemonstratesymptoms.14,15ResearchersattheDepartmentofDefense(DoD)GlobalEmergingInfectionsSystemandtheWalterReedArmyInstituteofResearcharecoordinatingtoevaluatepre-andpostdeploymentbloodsamplesfromSoldierspreviouslydeployedtoKoreatodeterminerelativeratesoftransmissioninlieuofnosymptomaticcasesreportedamongUSSoldiersoverthepast2decades.Currently,theUSprotocolinKoreaforJEvaccinecategorizesinoculationasvoluntaryuponrequestbytheindividual.Japaneseencephalitisismaintainedintheenvironmentthroughamosquitolargewadingbirdmosquitocycle.Theprincipalvectorsprefertofeedonbirds,butwillfeedonalternatehostswhenbirdsarenotavailableorwhenthealternatehostsenterthemosquitoeshabitat.16Pigsservetoamplifythetransmissioncycle,producingextremelyhighviremiasthatinfectlargenumbersoftheblood-feedingvectormosquitoes.17Japaneseencephalitisinfectioncausesspontaneousabortioninsowsabouttolitter.Forthisreason,breedersowsareoftenimmunized.However,becauseofthecostsandtheabsenceofeffectonproduction,youngpigsraisedforslaughterarenotimmunizedsincevirusinfectionsdonotaffecttheirhealthorweightgain.Whenmilitarypersonnelresideortrainnearvectormosquitohabitats,suchasricepaddieswherelargewadingbirdsarepresentandespeciallynearpigfarmswhenJEiscirculating,theyareathighriskforinfection.Therefore,riskassessmentsconductedforJEshouldconsidertheseasonalityandproximityofswinefarmstoUSmilitaryinstallationsandtrainingsites.TheKNIHconductsmosquitosurveillance.WhenJEvectorpopulationsexceed50%ofthecollectedmosquitoes,theKNIHissuespublicJEalerts,remindscitizenstouseallmeanstoprotectthemselvesfrommosquitobites,andencourageshighriskgroupstoobtainvaccinations.However,theareaswheretheKoreanworkforceconductssamplingareoftennotthesameareasofinterestasthoseoftheUSarmedforces.Additionally,theKNIHconductssero-surveillanceforthepresenceofJEantibodies/infectionfromslaughteredpigsatselectedsentinelsites.TheKNIHagainreportstheresultsinpublicnewsreleases,whichemphasizevaccinationandPPM.However,thesedatadonotreflectthefocalinfectionssince:sentinelsitesarelimited;onlydatafromslaughterhousesarereported,notthepigfarmsiteswherethetransmissionoccurred;andpigfarmsareisolatedandnotevenlydistributed.Whilethesedataarelimited,theyserveasanearlywarningsystem.Forexample,priortotheimmunizationprogram,itwasobservedthatapproximately2weeksafterthepigswereserologicallypositiveforJE,mosquitosampleswereidentifiedaspositive,andshortlythereafter,focaloutbreaksofJEinhumanpopulationsresulted.Asthestructure,distribution,andconcentrationofUSmilitaryforceschangeinKoreainresponsetotransformationandbaseclosures,vector-bornediseasesmustbeconsidered,forexample,themovementofforcescurrentlydeployednorthofSeoultoCampHumphreys(nearPyeongtaek),whichisprogrammedtobecometheprimaryUSArmyinstallationontheKoreanpeninsula.Currently,muchofCampHumphreysissurroundedbyricepaddiessurveillancein2005and2006demonstratedlargepopulationsofCulextritaeniorhynchusoccurredfromAugustthroughearlyOctober.ThedemographicsofthisinstallationwillchangefromaSoldierbasedcommunitytoaSoldierandfamilymemberbasedcommunity,placingfamilymembers,includingyoungchildren,atriskinanareaweretheymaybeexposedtolargepopulationsofpotentiallyinfectedvectors.Inaddition,2of7JEcasesreportedinthehighlyvaccinatedKoreanpopulationduring2007residednearPyeongtaek,suggestingthatimplementationofaJEvaccinationprogramisnecessarytoprotectthesusceptibleandgrowingUSpopulationatCampHumphreys.Thus,constantsurveillanceofmosquitopopulations,theirinfectionrates,andcoordinationwiththeKNIHandKoreaCenterforDiseaseControlandPreventionisnecessarytodelineatetherisksandreducethethreatofJapaneseencephalitistoUSpopulations.MALARIAANDJAPANESEENCEPHALITISPREVENTIONANDCONTROLSTRATEGIESReadinessisakeyissuewithUSmilitarypersonnelintheROK.TheproximityanduncertaintyofarapidlyPerspectivesofMalariaandJapaneseEncephalitisintheRepublicofKorea

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AprilJune200871THEARMYMEDICALDEPARTMENTJOURNALescalatingenemythreatdictatethatcommandersandtheirSoldiersmustbepreparedforhostileactionsandtrainastheyfight.Thisincludesthepreventionofdiseaseandnonbattleinjuries,especiallythoseduetopreventablediseases.CommandemphasisandroutineimplementationofPPMisessential.ItnotonlydecreasesthepotentialformalariaandJEtransmission,butalsodecreasestheprobabilityofcontractingscrubtyphusandmultipletick-bornediseases.Italsoservesasanalerttocommandersforotherdiseases(ie,Hantaanvirus),wherePPMand/orotherstrategiesmustbeemployed.Thepreventionofmosquito-bornediseaseinendemichigh-riskareasoftheROKrequiresstrictadherencetotheDoDInsectRepellentSystem,toincludethemandatoryuseofbednetsduringovernightfieldtrainingevents.In2007,theEighthArmypurchasedbednetsforusebymilitarypersonnelwhoconductedovernighteventsinmalariahigh-riskareasneartheDMZ.BarracksalsoreplacedthetentvillageatWarriorBaseandwerethoughttohaveanadditionalbenefitofpreventingvectorSoldierinteractions.ItwaslaterobservedthatSoldierswouldgatheroutsideduringoff-dutyhoursandatnightinshortsandt-shirtstosocialize.Thus,theirbehaviorexposedthemtopotentiallyinfectedmosquitoes,eventhoughtheyallhadthemeanstopreventmosquitoesfrombitingthemandgettingmalariaorotherdiseases.Therefore,humanbehaviorscontinuetoserveasmajorriskfactorsandcannotbeoverlooked.Chemoprophylaxis(chloroquinewithterminalprimaquine)maybeusedtoreducetherisksofacquiringmalaria.18Whileitdoesnotpreventtransmissionorinfection,itdoesreducethereservoirpopulation(infectivehumans)requiredforthetransmissionofmalariatoROKciviliansandUSmilitarypersonnellivingordeployedincloseproximitytoROKbasesneartheDMZ.However,aneffectivechemoprophylaxisprogramrequiresstrictadherencetopolicyandobservedcompliance.19,20AsaresultofincreasingmalariaratesobservedinUSandROKpopulationsin1998,theEighthUSArmyplacedallUSSoldierstrainingneartheDMZonchemoprophylaxis.Commandersapparentlydidnotunderstandtheprogramasthereweremanyvariations(eventandsituationaldependent),includingnoncompliancewithterminalprimaquine(15mgdailyfor14daysafterthemalariaseasonorwhendepartingmalariahigh-riskareas).ThisresultedinanincreasedproportionofUSdiagnosedmalariacasesbeingattributedtoexposureinKorea.BasedonrecommendationsfromthePreventiveMedicineandEntomologyConsultants,ForceHealthProtection,18thMEDCOM,after1999thechemoprophylaxispolicywaschanged:OnlythoseSoldiersresidinginmalariahigh-riskareas(CampBonifas-JointSecurityAreaatPanmunjomandCampGreaves)areplacedonchemoprophylaxis.CommandemphasisisplacedonpreventionusingPPMthatincludesproperwearoftheuniform,impregnatinguniformswithpermethrin,andusingthestandardmilitarytopicalinsectrepellentswhileinfieldenvironmentsneartheDMZ.Effortstocombatmosquitoeswithultralowvolume(ULV)orthermalfoggerspresentseveralissuesforUSmilitaryforcesinKorea.First,forvariousreasons,trainingareasarenottreated,soPPMandothermitigationstrategiesmustbeemployedinthoseareas.Second,USbaseswheremosquito-bornediseasesareathreatareusuallysurroundedbyricepaddiesandassucharebasicallyislandsinaseaofmosquitohabitat.Third,adulticidesappliedbyULVareeffectiveoverashorttimeanddistancebutdonotsignificantlyslowthemigrationofmosquitoesfromthesurroundingricepaddies.Fourth,pesticideresistanceisacontinualconcernassomepopulationsofmosquitoesareresistanttoatleastoneofthepesticidesusedbytheKoreanhealthofficials.Thus,healthdepartmentshaveresortedtoacocktailofinsecticidesratherthanonespecifictype.However,itisthoughtthatmostmosquitopopulationsaresusceptibletopesticidescurrentlyusedbytheUSmilitary,althoughtherehavebeennostudiestoconfirmthissupposition.Onbases,Soldierstendtoescapetheaffectsofvector-bornediseasebecausetheyarenormallyinsidefromdusktodawn,theprimarymosquitofeedingtimes.Somebasesarestilllocatedinurbanareaswherevectorpopulationsarelow,furthersuggestingthatthegreatestriskformosquito-bornediseaseisduringovernightfieldtrainingevents.Plantingvegetativebordersalongtheperimeterofinstallationsthataresurroundedbyricepaddies,thentreatingthe

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72www.cs.amedd.army.mil/references_publications.aspxvegetationwithsemipersistentchemicalsmayreducevectorpopulationstoacceptablelevels.Thisreductionwouldoccurasmosquitoesarekilledwhentheycomeintocontactwiththepesticidewhilerestingonthevegetationduringtheirmovementfromoff-posttoareaswheretheSoldiersreside.Currently,noneoftheUSinstallationsorfieldtrainingsiteshaveperimetervegetationthatmeettherequirementsforbarriersprayapplicationandcontrol,and,ofcourse,theefficacyofthiscontrolstrategyshouldbetestedbeforefullimplementation.Additionally,larvalsurveillancethatidentifiessourcesofvectorpopulationsonornearUSinstallationsmustbeconducted.OnUSinstallations,thesesitesmustbeidentifiedondetailedmapstoensurecontroltechniquesareimplemented(eg,drainageofwatersourcesandapplicationoflarvicides)toreducevectorpopulations.Iflarvicidesareappliedtowatersources,theymustbesurveyedperiodicallytoensurethattheyareeffective.Pre-andpostsurveillancemustalsobeconductedwhenpesticidesareappliedtocontroladultpopulations,especiallysincepreliminaryobservationsofULVapplicationindicatethatitiseffectiveforlessthanonehourafterapplication.NewJerseylighttraps(NJLT)havebeenusedformosquitocollectionsincetheendoftheKoreanWar.Thesetrapsuselightasanattractantandthereforerequirelightsecuritywheretheyareemployed.Also,duetosecurityatUSmilitaryinstallations,therearefewplaceswherelightswhichinterferewiththecollectionsofmosquitoesarenotpresent.Becauselightisusedasanattractant,allinsectsattractedtolights(ie,moths,flies,beetles)arecollected,whichresultsindamagedmosquitospecimensthatcannotbeidentified.Furthermore,akillingagentisplacedinthecollectionchamberthatrapidlykillsmosquitoes,renderingthemuselessforvirusisolation.However,newerinnovativemosquitotrapshavebeenevaluatedthatdonotdependuponlightsecurity,collectlargernumbersofmosquitoes,andcollectmosquitoesalivesothatvirusinfectionratescanbedetermined.Forexample,theMosquitoMagnet,usesCO2andheatasattractantsandselectivelycollectsmosquitoes.Octenolcanbeaddedasanattractantandactstoattractmoreofsomespecies,butrepelsothers(eg,CulexpipiensandCulexorientalis).Ingeneral,moreAnophelesmosquitoesarecapturedintheMosquitoMagnetsusingoctenolthaninothermosquitotraps,buttheincreasedattraction/repellencyhasnotbeendeterminedforeachspecies.Whilethesetrapsprovidemanyadvantagesportable,canbeusedinareaswithoutelectricitysuchasfieldtrainingsites,collectlargenumbersofmosquitoes,live-capturemosquitoesinrelativelygoodconditionsotheycanmoreeasilybeidentifiedandusedforvirusisolationsoverthestationaryNJLT,theyrequirepropane(anexplosivegas)andmustbesecured.ResultsoftheuseofMosquitoMagnetsdemonstratedtheirutilityintheidentificationofJEinfectionratesinmosquitoesashighas3.3/1,000and0.3/1,000atWarriorBase;therebyidentifyingthefocaltransmissionandepidemicpotentialofthisvirus.CONCLUSIONVivaxmalariaandJapaneseencephalitisremainvalidthreatstomilitarypopulationsinKorea.TheprimarythreatofmalariaisnorthofSeoulandalongtheDMZ.TravelhistorywithinKoreaisimportantinunderstandingKoreanmalariaissues,andleadersmustremembertodeterminethesiteoftransmissionandnotthesiteofdiagnosiswhenimplementingpreventionandcontrolmeasures.RecentstudieshaveprovidednewinformationontheacuteandlatentformsofKoreanmalaria,theidentificationofnewAnophelesspecies,andtheincriminationofpotentialmalariavectorsandtheirhabitats.Japaneseencephalitiscontinuestocirculateinavianandswinepopulations.KoreanvaccinationprogramshavesignificantlyreducedJapaneseencephalitisexpressioninhumans.However,withthemovementofUSmilitarydependentpopulationstoCampHumphreys,theUSmilitaryJapaneseencephalitisvaccinationandpreventionpoliciesforthissusceptiblepopulationmustbereevaluated.Studiesareneededtodeterminepracticalcontrolstrategiesfor"islandpopulations"ofsusceptiblehosts,suchasarefoundonsomeUSmilitaryinstallationsinKorea.Finally,militaryorganizationsperformingvectorsurveillancestudiesintheROKshouldcoordinatetheirvisitwiththeForceHealthProtectionstaffatthe18thMEDCOMandthe5thMedicalDetachment.Theseorganizationscurrentlyhaveresourcesandcollaborationsforin-countrysupportontheidentificationofvectors,rearingimmaturevectorstoPerspectivesofMalariaandJapaneseEncephalitisintheRepublicofKorea

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AprilJune200873THEARMYMEDICALDEPARTMENTJOURNALtheadultstage,informationregardingmalariainterviews,andcollaborativesupportwithKoreanhealthorganizationsanduniversities.REFERENCES 1.MarshallIH.MalariainKorea.In:RecentAdvancesinMedicineandSurgeryBasedonProfessionalMedicalExperiencesinJapanandKorea1950-1953[professionaleducationcourse,19-30April,1954].Vol.2.MedicalSciencePublicationNo.4.Washington,DC:USArmyMedicalServiceGraduateSchool,WalterReedArmyMedicalCenter;1954:270-283.Availableat:http://history.amedd.army.mil/booksdocs/korea/recad2/ch6-2.htm.2.WorldHealthOrganization.Synopsisoftheworldmalariasituation,1979.WklyEpidemiolRec.1981;56:145-149.3.FeighnerBH,PakSI,NovakoskiWL,KelseyLL,StrickmanD.ReemergenceofPlasmodiumvivaxintheRepublicofKorea.EmergInfectDis.1998;4:295-297.4.ChaiIH,LimGI,YoonSN,OhWI,KimSJK,ChaiJY.Occurrenceoftertianmalariainmalepatientswhohaveneverbeenabroad[inHangul].KoreanJParasitol.1994;32:195-200.5.ChoSY,KongY,ParkSM,etal.TwovivaxmalariacasesdetectedinKorea.KoreanJParasitol.1994;32:281-284.6.ReeHI.UnstablevivaxmalariainKorea.KoreanJParasitol.2000;38:119-138.7.ParkJW,KleinTA,LeeHC,etal.Vivaxmalaria:acontinuinghealththreattotheRepublicofKorea.AmJTropMedHyg.2003;69:159-167.8.HanET,LeeDH,ParkKD,etal.Reemergingvivaxmalaria:changingpatternsofannualincidenceandcontrolprogramsintheRepublicofKorea.KoreanJParasitol.2006;44:285-294.9.ServiceMW.Mosquitoes(Culicidae).In:LaneRP,GrosskeyRW,eds.MedicalInsectsandArachnids.London,UK:Chapman&Hall;1993:120-240.10.LeeWJ,KleinTA,KimHC,etal.Anopheleskleini,An.pullus,andAn.sinensis:potentialvectorsofplasmodiumvivaxintheRepublicofKorea.JMedEntomol.2007;44:1086-1090.11.RuedaLM,.TwonewspeciesofAnopheles(Anopheles)HyrcanusGroup(Diptera:Culicidae)fromtheRepublicofSouthKorea.Zootaxa.2005;941:1-26.12.SabinAB,SchlesingerRW,GinderWR,MatsumotoM.JapaneseBencephalitisinanAmericanSoldierinKorea.AmJHyg.1947;46:356-375.13.SohnYM.JapaneseencephalitisimmunizationinSouthKorea:past,present,andfuture.EmergInfectDis.2000;6:17-24.14.HalsteadSB,GroszCR.SubclinicalJapaneseencephalitis.I.InfectionofAmericanswithlimitedresidenceinKorea.AmJHyg.1962;75:190-201.15.HuangCH.StudiesofJapaneseencephalitisinChina.AdvVirusRes.1982;27:71-101.16.PantCP.ControlofvectorsofJapaneseencephalitis.Geneva:WorldHealthOrganization;1979.Availableonrequest[WHO/VBC/79.733]fromDivisionofControlofTropicalDiseases,WorldHealthOrganization,1211Geneva27,Switzerland.17.BurnsKF,TigerttWD,MatumotoM.Japaneseequineencephalomyelitis:1947epizootic.II.Serologicalandetiologicalstudies.AmJHyg1949;50:27-45.18.ParkJW,KleinTA,LeeHC,etal,Vivaxmalaria:acontinuinghealththreattotheRepublicofKorea.AmJTropMedHyg.2003;69:159-167.19.GambelJM,BrundageJF,BurgeRJ,DeFraitesRF,SmoakBL,WirtzRA.SurveyofUSArmySoldiersknowledge,attitudes,andpracticesregardingpersonalprotectivemeasurestopreventarthropod-relateddiseaseandnuisancebites.MilMed.1998;163:695-701.20.GambelJM,BrundageJF,KuschnerRA,KelleyPW.DeployedUSArmySoldiers'knowledgeanduseofpersonalprotectionmeasurestopreventarthropod-relatedcasualties.JTravMed1998;5:217-220.AUTHORS LTCSamesisassignedtotheDefenseLogisticsAgency,FortBelvoir,Virginia.Previouslyhewastheentomologyconsultanttothe18thMedicalCommand,YongsanGarrison,Seoul,SouthKorea.COL(Ret)Kleinisaconsultanttothe18thMedicalCommand,YongsanGarrison,Seoul,SouthKorea.DrKimistheEntomologyLaboratoryleader,5thMedicalDetachment,YongsanGarrison,Seoul,SouthKorea.

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74www.cs.amedd.army.mil/references_publications.aspxOneofthelegaciesofthemilitarycampaigninthePersianGulfistherealizationthatthepublichealthtollofaconflictisnottrulyknownatthetimethedeploymentends.Concernsregardingdelayedhealtheffectsmayextendthemedicalmissionforyears.InaJanuary2003WashingtonPostarticle,DavidBrown1describedanewsystemtokeephealthsyndromesatbay.HenotedthattheagonizinginvestigationofwhatcametobeknownasGulfWarsyndromeerodedtrustinthemilitary,costhundredsofmillionsofdollarsandconsumedthousandsofyearsofhumanlabor.Brownacknowledgedthattheinabilityofthemilitarytoprovideanswerstoquestionsrelatingtoexposures,trooplocation,falsechemicalalarms,andpredeploymenthealthstatusamongotherconcernsfueledabeliefthathorriblethingsmayhaveoccurredduringthewar.militaryhealthofficialsandmostcivilianresearcherswhostudiedthesubjectdonotbelieveanythingunusualorundiscoveredoccurredintheGulfWartocausechronicillness.Thistime,themilitaryisdeterminedtobeginandconcludetheconflictwithmuchbetterinformation.Brownalsoaddressedtheinformationthatisbeingcollectedtocharacterizeoccupationalandenvironmentalexposures,anditspotentialuses.THEEVOLUTIONOFTHEOCCUPATIONALANDENVIRONMENTALHEALTHASSESSMENTEffortstocharacterizeoccupationalandenvironmentalhealth(OEH)exposuresindeployedsettingshavematuredsubstantially.DuringthedeploymenttotheBalkans,healthsurveillancepolicystressedaneedtoidentifyhealththreatsintheater,routinelyanduniformlycollectandanalyzeinformationrelevanttotroophealth,anddisseminatethisinformationinatimelymanner.USArmypreventivemedicinepersonnelcollectedair,water,andsoilsamplesfromavarietyoflocations,largelyoutofconcernaboutindustrialcontamination.Theambientairwasmonitoredforvolatileorganiccompounds,semivolatileorganiccompounds,particulatematterlessthan10mindiameter(PM10),andassociatedmetals.Themainsourceofparticulatewascoal-firedpowerplants.Samplingindicatedintermittentdetectionsofvolatilecomponentsoffuelatconcentrationsthatwerenotsufficienttoproduceacutehealtheffects,and,thepotentialforchronichealtheffectswasconsideredminimalduetointermittentexposuresatvariedlocations.Atonelocationnearaleadsmelter,ambientsamplingindicatedelevatedlevelsoflead.BloodleadtestingwasperformedtoassessexposureoftheKosovoPeacekeepingForces.Fortunately,thesmelterultimatelyclosed.Nearly600PM10samplesweretakenandcomparedtoUSEnvironmentalProtectionAgency(EPA)AirQualityIndexlevels.Sixtypercentofthesampleswereinthegoodcategory,wherenohealtheffectsareexpected.Another38%wereinthemoderatecategory,withlessthan2%categorizedasunhealthyforsensitivegroupsorunhealthyingeneral.2ThesecategoriesandcorrespondinglevelsareusedintheUStoalertthepopulationandsensitivesubgroupssuchaselderly,children,andthosewithheartandlungdiseasewhenoutdooractivitycouldbehazardoustotheirhealth.Limitedenvironmentalregulationsallowedpollutionofsurfacewaterswithrawsewageandindustrialwastes.WhileUSforcesdrankbottledwater,waterforcooking,laundry,andshowerswasproducedlocallybyreverseosmosiswaterpurificationunitsandtreatedmunicipalsupplies.FinishedwaterdidnotexceedanyoftheUSEnvironmentalProtectionAgency(EPA)primarydrinkingwaterstandards.SoilsamplingwasalsoperformedandcomparedtotheEPArisk-basedguidelines,and,giventhelimiteddurationofexposure,noconcernswerenoted.ANTICIPATIONANDHAZARDRECOGNITIONThecurrentOEHassessmentprocessfocusesonhazardanticipationaswellasrecognition.Priortothelocationofasite,plannerscanrequestapreliminaryhazardorPhaseIassessmentfromtheGlobalThreatHealthImplicationsofOccupationalEnvironmentalHealthSamplingColeenWeese,MD,MPH

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AprilJune200875AssessmentProgram.*Thisprocessidentifiesindustryandotherrelevantfeaturesofalocation,pastuseandpractices,aswellasavailableintelligence.Thiscanbeusedtoguideintheselectionofalocation,andtofocustheOccupationalandEnvironmentalHealthSiteAssessment(OEHSA).OneoftheinitialactionstakenbypreventivemedicinepersonneluponarrivalatasiteistheOEHSA.Thisisanoverviewofthelocationthatsurveyspotentialhealthrisks,samplessoilandwater,andinvestigatesfocalconcernssuchasstainedsoilthatmightindicateafuelspill,storedordiscardedtoxicmaterialcontainers,orproblemsfromlocalindustryoroperations.Thesefindingsaresummarizedandserveasastartingpointforperiodicbasecampassessments.Whiletheactualsamplingfrequencyandextentmayvarywiththesizeofthecamp,thelocation,oritspopulation,atypicalanalysisincludessoilandwatersampleswhichareanalyzedforpesticides,volatileandsemivolatilecompounds,andmetals.Currenttechnologyanalyzesforpresenceofcompounds,identifiesthosepresent,andquantifiestheamount.Typically,ambientairsampling,noise,andentomologicalandradiationsurveysarealsoconducted.TheresultsarestoredintheDefenseOccupationalandEnvironmentalHealthReadinessSystem(DOEHRS)dataportal,maintainedandoperatedbytheUSArmyCenterforHealthPromotionandPreventiveMedicine(USACHPPM).USACHPPMSROLEINOCCUPATIONALANDENVIRONMENTALHEALTHSURVEILLANCEANDSUPPORTTheUSACHPPMprovidesconsultativeassistance,equipment,andanalyticalsupporttodeployedpreventivemedicineunits.Standardizedguidancedocumentsanddecisioncriteriaprovideaframeworkforhazardidentification,exposuremonitoring,andoperationalriskassessment.USACHPPMalsoprovidestrainingontheuseoftechnicalguidanceandenvironmentalmonitoringequipment.OEHhazarddataisarchivedalongwiththegeographiclocation.Since2005,ambientsamplingdatalinkedtoabaselocationcanbematchedwitharosterofthebasecamppopulationtoidentifyapopulationatrisk.Presently,theUSACHPPMdataarchivesholdstensofthousandsofsampleresults.Thesemayexistasspreadsheetsofdataconsistingofvariousconcentrationsofunfamiliarcompoundstiedtoalocation,withoutaclearconnectiontoadefinedpopulationatriskorknownexposuredurations.Clearly,interpretationmustoccurbeforethisinformationisusefulforanyconsiderationofimpacttohealth.Duringthe1990s,theUSACHPPMattemptedtoidentifyexistingexposureguidelinestouseforcomparativepurposes.Occupationalexposurevaluesexistformanycompounds,forexample,theThresholdLimitValues,orTLVs,whichrefertoairborneconcentrationsofsubstancesandrepresentconditionsunderwhichitisbelievedthatnearlyallworkersmayberepeatedlyexposeddayafterdaywithoutadversehealtheffects.4Somearenear-effectlevelsbasedonstudiesofworkers,insettingswheremonitoringofindustrialhygienedocumentedexposures.Othersarebasedonscarcetoxicologicaldataandextrapolations.Asawhole,thequantityandqualityofdataonwhichtheyarebasedvaries,resultingindifferinglevelsofuncertainty.Theseoccupationalguidelinesaretypicallyusedtodeterminewhenaworkershouldbeenrolledinmedicalsurveillance.Theyarealsousedbyindustrialhygieniststodetermineifexposurereductionisneeded,andifcontrols,includingpersonalprotectiveequipment,shouldbeimplemented.Anothersourcewasthoseguidelinescreatedforuseinenvironmentalassessmentandcleanup.Theseoftenassumea24-hour,daily,lifetimeexposure,andaretypicallyderivedtoprotectchildren,pregnantwomen,andothersensitivepopulations.Thesearenoteffectlevels,butconservativeguidelineswhichincludesafetyfactorsthatcanserveasclean-upgoalsbeforelocationsareconsideredacceptableforunrestrictedaccess,oruseasahomesiteorpark.Additionally,shorttermexposureguidelinesexistforacuteeventssuchasachemicalrelease.Noneoftheguidelinesentirelyaddressthedeploymentexposurescenarioa *TheGlobalThreatAssessmentProgram,afunctionofUSACHPPM,identifiesandassessesdeploymentOEHhazardsandthreatsforworldwideprioritydeploymentareas,bothexistingandplanned.TheseassessmentsareusedbytheOEHsurveillanceactivitiesthatsupporttheintelligencepreparationoftheenvironmentduringoperationalplanning.3DefenseOccupationalandEnvironmentalHealthReadinessSystemisanintegratedenvironmental,safety,andoccupationalhealthapplicationsupportingDepartmentofDefenseinitiativestocapture,store,andanalyzetheexposurehistoryofmilitary-relatedpersonnelthroughouttheirlife.Source:DoDHealthAffairs.Availableat:http://www.ha.osd.mil/peo/ritpo/ritpo_01.aspAvailableat:https://doehsportal.apgea.army.mil/doehrs-oehs/Authorizedusersonly.

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76www.cs.amedd.army.mil/references_publications.aspxrelativelyfit,healthyforce,potentiallyexposed24hoursperdayforaroughly12to15monthperiodorless.Additionally,samplingindicatesapointexposure,butanyoneindividualisunlikelytobeatanyspotonabasecampfor24hoursperday.Therefore,existingguidelinesweremodifiedtoderivetheMilitaryExposureGuidelines.FROMCONCENTRATIONSTOCONCLUSIONSMilitaryExposureGuidelines(MEGs),arescreeninglevelsforspecifiedexposuredurations,forhundredsofchemicalsinair,water,andsoil.ThesescreeninglevelsarefoundintheUSACHPPMTechnicalGuide2305andwerederivedfromexistinglevelsestablishedbyotherorganizations,suchastheEPA,oroccupationalstandards,asdiscussedabove,modifiedtofitthedeployedpopulationandtimeframe.Aswithanyguideline,itsusenecessitatesanunderstandingofwhetheritrepresentsascreeningleveloranactionlevel.Forexample,whenexceeded,someoccupationallevelsnecessitateaspecificactiononthepartofanemployerwhichmightbetocontrolorreducetheexposureandpotentiallyinitiateamedicalaction.Incontrast,screeningvalues,suchasthoseusedbytheEPAinenvironmentalassessment,areconservativeandthusanexceedanceisanindicationthatfurtherevaluationmaybenecessary,thatsomeremediationshouldoccur,etc.However,anexceedanceisnotlikelytoindicateaspecificmedicalactionforanyindividualorpopulation.Othervaluesthathavebeenderivedforemergencyplanningpurposesalsohavesomesafetyfactorsbuiltin,buttheuncertaintyisusuallyless,soexceedancesmaybeassociatedwithspecificactions.TheMEGsarescreeningvalues,notactionlevels,andwerereviewedbytheCommitteeonToxicologyoftheNationalAcademyofSciencesaspartoftheDepartmentofDefense(DoD)approachtoOEHassessment.TheCommitteeconsideredthemappropriateforceprotectivescreeningvalues,usefultoprovideinformationtoacommanderandtoguidefurtheractions.Ontheotherhand,theCommitteeagreedthatMEGswerenotcasualtyestimatesandthatexceedancesdidnotindicatethatahealtheffectwaslikelyintheexposedpopulation.6Thispointisoftenmissedormisunderstood,particularlyinthecontextofmedicalactions,documentation,andpotentiallylong-termsurveillanceandcompensation.SowhatistheappropriateuseofaMilitaryExposureGuidelineinOEHassessment?WhenacontaminantismeasuredabovetheMEGappropriateforthepresumeddurationofexposurethereareshort-termandlong-termMEGSthereissomespaceforevaluation.Thisisdonebylookingatpotentialhealtheffectsassociatedwithmeasuredlevels.Giventhatthescreeningguidelineshavesomebuilt-insafetyfactors,theremaybenohealtheffects.Thisstepidentifiesthehealthseverity.Thenextstepistoexaminethelikelihoodofexposuresandprobability(numberofsamples,etc).Onceahealththreathasbeenidentifiedanditshealthseverityandprobabilitydetermined,theriskiscomparedtoothersintheprocessofoperationalriskmanagement,aprocessforidentifying,assessing,andcontrollingrisksfromoperationalhazards,includingOEHhazards.7Riskisdeterminedbyestimatingtheprobabilityandseverityofapotentialadverseimpactthatmayresultfromhazardsduetothepresenceofanadversaryorsomeotherhazardouscondition(ie,environmentalcontamination).Risksrangefromlowthroughextremelyhigh.Forexample,theArmysOEHhazardoperationalriskmanagement(ORM)assessmentsfor2005arepresentedinTable1.LeadersseektomitigateriskbyevaluatinghazardsandimplementingORMoptionsduringoperationalplanning.Whenappliedbymedicalpersonnel,theORMprocessallowsplannerstoincludetheassessmentoftheseverityofhazards,characterizetherisksinthecontextoftheproposedoperation,andtheneffectivelycommunicatetheriskassessmentsandappropriatecontrolmeasureoptionstothecommander.CommandersthenmakeinformeddecisionsbybalancingtheOEHrisksandotheroperationalriskswithmissionrequirements.GiventhatORMisintendedtofocusonoperationalrisktoamission,OEHexposureswithacuteeffectsandimpactareweightedmoreheavily.ACUTEVERSUSDELAYEDHEALTHRISKSTypically,acuteexposuresarecharacterizedashighenoughtocauseaneffectimmediately,orintheshortterm(hoursordays).Whiletheyareeasiertomeasure,andeasiertointerpretandrelatetoahealtheffect,itmaybelesslikelythatmonitoringinformationexistsbecausetheyareoftenunanticipated.Examplesmightincludeafuelspillimpactingwater,areleaseofmetalsorotherchemicalsduetoafireorburningofmaterials,oranemissionfromindustryduetolessstringentcontrolsordiminishinginfrastructure.HazardsassociatedwithacuteeffectsmayimpactHealthImplicationsofOccupationalEnvironmentalHealthSampling

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AprilJune200877THEARMYMEDICALDEPARTMENTJOURNALoperations,andassucharegivenahigheroperationalriskthanhazardswithdelayedeffects.However,amemorandumissuedbytheJointChiefsofStaffinNovember2007,8introducednewhazardseveritycategoriesforuseinORMthataddressbothacuteandchroniceffects.ThoseseveritycategoriesarepresentedinTable2.8(pB-9)Theintentwastoinformcommandersofthepotentialeffectsthatmightnotimpacttheoperation,butwhichmightbeforcehealthprotectionconsiderations.ThissupportstheDoDrequirementtodocumentexposuresthatcancauselatenthealtheffectsand,whenindicated,conductlong-termmedicalsurveillance.9Itisquitedifficulttomeetthisrequirementifaproviderdoesnothaveaccesstothedataortheinterpretation.Lowerlevelsofhazardswhichmayposeachronicrisk,orcontributetoorcauseadelayedhealtheffectaresubstantiallymorecomplicatedtoevaluate.Itismorelikelythatroutine,nonincidentconditionsgeneratelevelsthatarerelativelylow,butmayonoccasionreachlevelsthat,ifsustained,couldposeachronicrisk.However,thisrequiresrelativelyconstantexposuretotheselevels.Levelsthatarenothighenoughtoposeanacuterisk,buthighenoughtobeofconcernforchronicexposuremayormaynotbetypicalorsustained.Additionally,definingthepopulationwhowouldexperienceasustainedexposureisdifficultsincepeoplemove,exposureconditionsaremorelikelytobevariablethenconstant,andsamplingismostoftenintermittent.However,longtermMEGsUSUnifiedCommandCountryInvolvedNumberofORMAssessmentsLowRiskModerateRiskHighRisk CentralCommand Afghanistan60508AmbientairbasedonPM10*2TreatedwaterqualityDjibouti,Egypt,Kenya,Ethiopia,Kyrgyzstan,Uzbekistan,UnitedArabEmirates,Yemen,SaudiaArabia31242AmbientairbasedonPM10*2TreatedwaterqualityIraq19512557PM10*andmetals9Treatedwaterquality2Rawwaterquality2PM10*andleadKuwait372016AmbientairbasedonPM10*1TreatedwaterqualityQatar1192AmbientairbasedonPM10* EuropeanCommand Bosnia,Georgia,Kosovo(Serbia),Morocco541Rawwaterquality SouthernCommand Antigua,Belize,DominicanRepublic,Columbia,Grenada,Guatemala,Haiti,Honduras,NetherlandsAntilles,Nicaragua,Panama17121Waterquality1Bottledwater2AmbientairbasedonPM10* NorthernCommand,JointTaskForce,Katrina UnitedStates1361332AmbientairbasedonPM10*1TreatedwaterqualityTotals49237892Ambientair19Waterquality2Ambientair1Waterquality*Particulatematterlessthan10mindiameterTable1.USArmyOccupationalandEnvironmentalHealthOperationalRiskManagement(ORM)AssessmentsPerformedDuringCalendarYear2005.

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78www.cs.amedd.army.mil/references_publications.aspx T a b l e 2 O p e r a t i o n a l H a z a r d S e v e r i t y R a n k i n g f o r O c c u p a t i o n a l a n d E n v i r o n m e n t a l H e a l t h H a z a r d s D u r i n g M i l i t a r y D e p l o y m e n t s D e s c r i p t i o n o f T y p e s o f H e a l t h E f f e c t s D r i v e r s f o r S e v e r i t y C a t e g o r y O p e r a t i o n a l S e v e r i t y R a n k N o n e N e g l i g i b l e M a r g i n a l C r i t i c a l C a t a s t r o p h i c A c u t e E f f e c t s N o e f f e c t s a r e a n t i c i p a t e d F e w e x p o s e d p e r s o n n e l ( i f a n y ) a r e e x p e c t e d t o h a v e n o t i c e a b l e a c u t e h e a l t h e f f e c t s d u r i n g m i s s i o n E x p o s e d p e r s o n n e l a r e e x p e c t e d t o b e a b l e t o e f f e c t i v e l y c o n d u c t a l l b a s i c f u n c t i o n s d u r i n g m i s s i o n o p e r a t i o n s M i n i m a l t o n o d e g r a d a t i o n o f a b i l i t i e s t o c o n d u c t c o m p l e x t a s k s a r e e x p e c t e d F e w e x p o s e d p e r s o n n e l ( i f a n y ) a r e e x p e c t e d t o h a v e n o t i c e a b l e a c u t e h e a l t h e f f e c t s d u r i n g m i s s i o n E x p o s e d p e r s o n n e l a r e e x p e c t e d t o b e a b l e t o e f f e c t i v e l y c o n d u c t a l l b a s i c f u n c t i o n s d u r i n g m i s s i o n o p e r a t i o n s M i n i m a l t o n o d e g r a d a t i o n o f a b i l i t i e s t o c o n d u c t c o m p l e x t a s k s a r e e x p e c t e d M a n y p e r s o n n e l a r e e x p e c t e d t o h a v e a c u t e d i s a b l i n g / i n c a p a c i t a t i n g h e a l t h e f f e c t s t h a t r e q u i r e i m m e d i a t e m e d i c a l t r e a t m e n t o r s u p p o r t ( e g a r e c o n s i d e r e d c a s u a l t i e s ) T h e r e m a y b e l i m i t e d n u m b e r s o f f a t a l i t i e s P e r s o n n e l n o t e x p e r i e n c i n g t h e s e m o r e s e r i o u s a c u t e e f f e c t s a r e e x p e c t e d t o h a v e a t l e a s t n o t i c e a b l e b u t n o t d i s a b l i n g h e a l t h e f f e c t s M a n y p e r s o n n e l w i l l h a v e l i m i t e d a b i l i t y t o c o n d u c t b a s i c t a s k s t h o u g h c o m p l e x s k i l l s m a y b e s i g n i f i c a n t l y d e g r a d e d M a n y c a s u a l t i e s w i t h s e v e r e a c u t e d i s a b l i n g / i n c a p a c i t a t i n g e f f e c t s r e q u i r i n g i m m e d i a t e a n d s i g n i f i c a n t m e d i c a l a t t e n t i o n a n d / o r a d d i t i o n a l s u p p o r t f o r s u r v i v a l I n c r e a s i n g n u m b e r o f d e a t h s E x p o s e d p e r s o n n e l u n a b l e t o p e r f o r m b a s i c p h y s i c a l a n d / o r m e n t a l f u n c t i o n s a n d / o r a n d / o r a n d / o r a n d / o r n o t a d r i v e r C h r o n i c E f f e c t s N o e f f e c t s a r e a n t i c i p a t e d F e w e x p o s e d p e r s o n n e l ( i f a n y ) a r e e x p e c t e d t o d e v e l o p d e l a y e d o n s e t i r r e v e r s i b l e e f f e c t s M a n y e x p o s e d p e r s o n n e l a r e p l a u s i b l y e x p e c t e d t o d e v e l o p d e l a y e d o n s e t i r r e v e r s i b l e e f f e c t s W h i l e t h i s m a y n o t a f f e c t t h e i m m e d i a t e p h y s i o l o g i c a l c a p a b i l i t i e s o f i n d i v i d u a l s c o m m a n d e r s m u s t c o n s i d e r l o n g t e r m i m p l i c a t i o n s a n d a p p r o p r i a t e l y c o m m u n i c a t e t h e r e s u l t i n g r i s k s P s y c h o l o g i c a l i m p l i c a t i o n s m a y a d v e r s e l y i m p a c t o p e r a t i o n s p a r t i c u l a r l y o v e r e x t e n d e d o p e r a t i o n a l p e r i o d s M a j o r i t y t o a l l e x p o s e d p e r s o n n e l a r e p l a u s i b l y e x p e c t e d t o d e v e l o p d e l a y e d o n s e t i r r e v e r s i b l e e f f e c t s d u e t o t h e s p e c i f i e d e x p o s u r e W h i l e t h i s m a y n o t a f f e c t t h e i m m e d i a t e p h y s i o l o g i c a l c a p a b i l i t i e s o f i n d i v i d u a l s c o m m a n d e r s m u s t c o n s i d e r l o n g t e r m i m p l i c a t i o n s a n d a p p r o p r i a t e l y c o m m u n i c a t e t h e r e s u l t i n g r i s k s P s y c h o l o g i c a l i m p l i c a t i o n s m a y a d v e r s e l y i m p a c t o p e r a t i o n s p a r t i c u l a r l y o v e r e x t e n d e d o p e r a t i o n a l p e r i o d s T h i s l e v e l o f h a z a r d s e v e r i t y i s r e s e r v e d f o r t h e m o s t s e r i o u s o f c o n d i t i o n s w h e r e i m m e d i a t e s u r v i v a b i l i t y a g a i n s t a c u t e e f f e c t s i s t h e p r i o r i t y T h o s e t h a t s u r v i v e e x p o s u r e s m a y b e a t i n c r e a s e d r i s k f o r c e r t a i n c h r o n i c h a z a r d s E f f e c t s a s s o c i a t e d w i t h a c h e m i c a l a r e t y p i c a l l y e i t h e r a c u t e o r c h r o n i c b u t i n s o m e c a s e s m a y b e b o t h I n g e n e r a l s h o r t t e r m s i n g l e e x p o s u r e s a r e p r i m a r i l y a s s o c i a t e d w i t h a c u t e e f f e c t s w h i l e r e p e a t e d l o n g t e r m e x p o s u r e s a r e a s s o c i a t e d w i t h c h r o n i c e f f e c t s T h e O R M r i s k a s s e s s m e n t p r o c e s s r e q u i r e s d e c i s i o n s t o b e b a s e d o n t h e m o s t o p e r a t i o n a l l y s i g n i f i c a n t r i s k w h i c h i s g e n e r a l l y d u e t o a c u t e h e a l t h e f f e c t s H o w e v e r t h e r e a r e c e r t a i n c i r c u m s t a n c e s w h e r e a c h r o n i c i r r e v e r s i b l e h e a l t h e f f e c t m a y d r i v e t h e O R M d e c i s i o n m a k i n g A c u t e e f f e c t s : H a v e r e l a t i v e l y i m m e d i a t e o n s e t ( s e c o n d s t o h o u r s ) W h i l e a c u t e e f f e c t s c a u s e d b y a h a z a r d a r e t y p i c a l l y r e v e r s i b l e c h r o n i c e f f e c t s m a y o c c u r s e c o n d a r i l y d e p e n d i n g o n t y p e o f h a z a r d a n d s e v e r i t y o f a c u t e e f f e c t E x a m p l e s : N o t i c e a b l e b u t n o t d i s a b l i n g e y e / u p p e r r e s p i r a t o r y i r r i t a t i o n c o u g h m i l d g a s t r o i n t e s t i n a l u p s e t g e n e r a l m a l a i s e D i s a b l i n g / i n c a p a c i t a t i n g d i f f i c u l t y b r e a t h i n g s e v e r e n a u s e a / d i a r r h e a i m p a i r e d v i s i o n ; S e v e r e p u l m o n a r y e d e m a s e i z u r e s c o m a C h r o n i c e f f e c t s : T y p i c a l l y h a v e a d e l a y e d o n s e t ( m o n t h s t o y e a r s ) a n d a r e g e n e r a l l y c o n s i d e r e d i r r e v e r s i b l e E x a m p l e s : c a n c e r c h r o n i c l u n g o r l i v e r d i s e a s e n e u r o l o g i c a l d a m a g e P a r t i c u l a r l y s i n c e t h e r e i s s u b s t a n t i a l v a r i a b i l i t y / u n c e r t a i n t y w i t h t h e s c i e n t i f i c e v i d e n c e b e t w e e n c e r t a i n o c c u p a t i o n a l / e n v i r o n m e n t a l e x p o s u r e s a n d c h r o n i c h e a l t h e f f e c t s t h e s e v e r i t y r a n k i n g m u s t f a c t o r i n t h e s c i e n t i f i c w e i g h t o f e v i d e n c e s u p p o r t i n g t h e l i n k b e t w e e n t h e s p e c i f i e d h a z a r d e x p o s u r e a n d t h e s p e c i f i c i r r e v e r s i b l e e f f e c t / d i s e a s e HealthImplicationsofOccupationalEnvironmentalHealthSampling

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AprilJune200879THEARMYMEDICALDEPARTMENTJOURNALarescreeningvaluesformorechroniceffectsandthemeasuredexposurewouldneedtobesustainedforlongperiods.Therefore,actionscanbetakentoreduceormitigatetheexposure.Typically,follow-upsamplingindicatesthattheexposureisnotlikelytobesustained,andthelongtermMEGisnotexceededonalong-termbasis.Intheeventofasignificantriskforadelayedhealtheffect,effortstoidentifytheexposedpopulationatriskandconductmedicalsurveillanceorepidemiologicalstudiescouldbeinitiated.DOCUMENTATIONOFEXPOSUREANDACCESSTOOEHEXPOSUREINFORMATIONDocumentationofsignificantOEHexposuresintheindividualmedicalrecordhasbeenrequiredbyDoD9(p8)forsometime.Inreality,althoughdatacollectionhasoccurred,thecontentandmethodofsuchdocumentationhasbeenasubjectofsomedebate.Significantisnotdefinedinthedocument,althoughonelinestatesthatexposuresthatresultinanacuteillnessorthathavepotentialtocauselatentillnesswillbeincludedinthepatientrecordsofthoseindividualsaffectedorpossiblyexposed.9(p12)TheaforementionedJointChiefsofStaffmemorandumspecifiestheneedtodocumentsignificantoccupationalandenvironmentalexposures,anddefinesthoseexposuresasexposuresthatwillplausiblyresultinclinicallyrelevantadversehealthoutcomestoexposedindividuals.8(pA-3)Whileitislikelythatindividualswhoseekcareforanacuteillnesswillhavedocumentationintheirmedicalrecords,itispossiblethatnosamplingwasavailablefortheincident.TherequirementtoincludeOEHexposuredatarelatedtopotentialdelayedeffectsnecessitatestheassemblyandsummarizationoflong-termsamplingdata.OEHdatafilesarelargeanddonotlendthemselvestoinclusionlikealabsliporindustrialhygienesample.Additionally,manyprovidersbelievethatlong-term,ambient,population-leveldata,asopposedtoindividualorpersonalsamples,donotbelonginamedicalrecord,butaremoreappropriateforepidemiologicalstudies.Finally,manyprovidersareunfamiliarwiththecompoundsandthebasisofscreeningguidelinesandwouldnotnecessarilybeabletousetheinformationtotakespecificactions.USAirForcesCentral*createdEnvironmental/OccupationalHealthWorkplaceExposuredataformsthatarepreparedbybioenvironmentalengineersandreviewedbymedicalpersonnel.AsArmyandAirForceunitsareoftencollocated,Armypersonnelhavesometimesrequesteddocumentation,andtheArmypreventivemedicineunitsinthefieldhavegeneratedStandardForm(SF)600sforsomesites.AnexampleofonesuchSF600foralocationinIraqisprovidedonpage80.AsubgroupoftheJointEnvironmentalSurveillanceWorkingGroup,workingwiththeUSCentralCommandSurgeonsofficeandpreventivemedicineorganizationsintheater,identifiedthetypesofentriesintheSF600madebythemilitaryservicestodate,andisidentifyingtheformatanddataelementstopromoteconsistency.USACHPPMhasinitiatedaparallelproceduretocreatesitesummariesfromtheORMreportscompletedforbasecampsthatareshorterandcanbeusedbyaphysicianwhodesiresinformationaboutabasecamp,aninterestedSoldier,theUSDepartmentofVeteransAffairs,ordeployedpreventivemedicineunitsthatarecreatingtheSF600s.Additionally,fullORMreports,sampleresultsbylocation,andotherinformationarestillaccessibletoanyonewithadesireorneedtoknowthroughtheDOEHRS.Theseeffortstodistillandlayerinformationforarchivingshouldmaketheinformationmanageableandusefulforthosewhoneedonlyasummarywiththeidentificationofanyconcerns.Throughouttheprocess,theidentificationofpotentiallong-termconcernscanbedocumentedandarchivedforcurrentorfutureuse.Astheseeffortscontinueandprogress,providerswillbecomefamiliarwiththetypesofOEHhealthrisksevaluatedintheatre,andcanusethisinformationforcommunicationwithpatients,andintheevaluationofindividualpatients.RequestsforassistanceandconsultationcanbeobtainedfromtheEnvironmentalMedicineProgramatUSACHPPM(http://chppm-apgea.army.mil). *TheUSAirForcecomponentofUSCentralCommandChronologicalRecordofMedicalCareTheJointEnvironmentalSurveillanceWorkingGroupwasestablishedin1997bytheAssistantSecretaryofDefense(HealthAffairs).ItservesasacoordinatingbodytodevelopandmakerecommendationsforDoD-wideOEHSpolicy.TheworkinggroupincludesrepresentativesfromtheArmy,Navy,andAirForceOEHShealthsurveillancecenters,theJointStaff,otherDoDentities,andVA.

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80www.cs.amedd.army.mil/references_publications.aspxREFERENCES1.BrownD.U.S.actstostemaGulfWarlegacymilitaryhopesnewsystemkeepshealthsyndromeatbay.WashingtonPost.January21,2003:A1.2.EnvironmentalSurveillanceAssessmentNo.47-EM-2638-00,EnvironmentalSurveillanceofKosovo,Mitrovica,Serbia,17-20June2000.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine.Availableat:http://chppm-www.apgea.army.mil/contactus.asp.3.KirkpatrickJS.Globalthreatassessmentprogram.ArmyMedDeptJ.April-June2006:51-54.4.2007TLVsandBEIs.Cincinnati,Ohio:TheAmericanConferenceofGovernmentalIndustrialHygienists;2007:3.5.TechnicalGuide230,GuideforDeployedPreventiveMedicinePersonnelonHealthRiskAssessment.Version1.3.AberdeenProvingGround,MD:USArmyCenterforHealthPromotionandPreventiveMedicine.2003.Availableat:http://chppm-www.apgea.army.mil/documents/tg/techguid/tg230.pdf.6.NationalResearchCouncil.ReviewoftheArmy'sTechnicalGuidesonAssessingandManagingChemicalHazardstoDeployedPersonnel.Washington,DC:NationalAcademiesPress;2004:12,76-77.7.FieldManual3-100.12:RiskManagement.FortMonroe,VA:USArmyTrainingandDoctrineCommand;February,2001.8.OfficeoftheChairman,JointChiefsofStaff.MemorandumMCM0028-07,ProceduresforDeploymentHealthSurveillance.WashingtonDC:USDeptofDefense;November2,2007.9.DepartmentofDefenseInstruction6490.03:DeploymentHealth.Washington,DC:USDeptofDefense;August11,2006.AUTHOR DrWeeseisProgramManagerforEnvironmentalMedicine,USACHPPM,AberdeenProvingGround,Maryland. Anexampleofanenvironmental/occupationalhealthworkplaceexposuredataformcompletedforaforwarddeployedlocationinIraq. HealthImplicationsofOccupationalEnvironmentalHealthSamplingTHEUSARMYCENTERFORHEALTHPROMOTIONANDPREVENTIVEMEDICINE

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SUBMISSIONOF M ANUSCRIPTSTOTHE A RMY M EDICAL DEPARTMENT J OURNAL The UnitedStatesArmyMedicalDepartmentJournal ispublishedquarterlytoexpandknowledgeofdomesticandinternational militarymedicalissuesandtechnologicaladvances;promotecollaborativepartnershipsamongtheServices,components,Corps, andspecialties;conveyclinicalandhealthservicesupportinformation;andprovideaprofessional,highquality,peerreviewed printmediumtoencouragedialogueconcerninghealthcareissuesandinitiatives. R EVIEW P OLICY Allmanuscriptswillbereviewedbythe AMEDDJournalsEditorialReviewBoardand,ifrequired,forwardedtotheappropriate subjectmatterexpertforfurtherreviewandassessment. I DENTIFICATIONOF P OTENTIAL C ONFLICTSOF I NTEREST 1. Relatedtoindividualauthorscommitments: Eachauthorisresponsibleforthefulldisclosureofallfinancialandpersonal relationshipsthatmightbiastheworkorinformationpresentedinthemanuscript.Topreventambiguity,authorsmuststate explicitlywhetherpotentialconflictsdoordonotexist.Authorsshoulddosointhemanuscriptonaconflict-of-interest notificationsectiononthetitlepage,providingadditionaldetail,ifnecessary,inacoverletterthataccompaniesthe manuscript. 2. Assistance: AuthorsshouldidentifyIndividualswhoprovidewritingorotherassistanceanddisclosethefundingsourceforthis assistance,ifany. 3. Investigators: Potentialconflictsmustbedisclosedtostudyparticipants.Authorsmustclearlystatewhethertheyhavedone sointhemanuscript. 4. Relatedtoprojectsupport: Authorsshoulddescribetheroleofthestudysponsor,ifany,instudydesign;collection,analysis, andinterpretationofdata;writingthereport;andthedecisiontosubmitthereportforpublication.Ifthesupportingsource hadnosuchinvolvement,theauthorsshouldsostate. P ROTECTIONOF H UMAN S UBJECTSAND A NIMALSIN R ESEARCH Whenreportingexperimentsonhumansubjects,authorsmustindicatewhethertheproceduresfollowedwereinaccordancewith theethicalstandardsoftheresponsiblecommitteeonhumanexperimentation(institutionalandnational)andwiththeHelsinki Declarationof1975,asrevisedin2000.IfdoubtexistswhethertheresearchwasconductedinaccordancewiththeHelsinki Declaration,theauthorsmustexplaintherationalefortheirapproachanddemonstratethattheinstitutionalreviewbody explicitlyapprovedthedoubtfulaspectsofthestudy.Whenreportingexperimentsonanimals,authorsshouldindicatewhetherthe institutionalandnationalguideforthecareanduseoflaboratoryanimalswasfollowed. G UIDELINESFOR M ANUSCRIPT S UBMISSIONS 1.Articlesshouldbesubmittedindigitalformat,preferablyanMSWorddocument,eitherasanemailattachment(with illustrations,etc),orbymailonCDorfloppydiskaccompaniedbyoneprintedcopyofthemanuscript.Ideally,amanuscript shouldbenolongerthan24double-spacedpages.However,exceptionswillalwaysbeconsideredonacase-by-casebasis.In general,4double-spacedMSWordpagesproduceasinglepageof2columntextinthe AMEDDJournal productionformat. 2.The AmericanMedicalAssociationManualofStyle governsformattinginthepreparationoftextandreferences.Allarticles shouldconformtothoseguidelinesascloselyaspossible.Abbreviations/acronymsshouldbelimitedasmuchaspossible. Inclusionofalistofarticleacronymsandabbreviationscanbeveryhelpfulinthereviewprocessandisstronglyencouraged. 3.Acompletelistofreferencescitedinthearticlemust beprovidedwiththemanuscript.Thefollowingisasynopsisofthe AmericanMedicalAssociationreferenceformat: Referencecitationsofpublishedarticlesmustincludetheauthorssurnamesandinitials,articletitle,publicationtitle, yearofpublication,volume,andpagenumbers. Referencecitationsofbooksmustincludetheauthorssurnamesandinitials,booktitle,volumeand/oreditionif appropriate,placeofpublication,publisher,yearofcopyright,andspecificpagenumbersifcited. Referencecitationsforpresentations,unpublishedpapers,conferences,symposia,etc,mustincludeasmuchidentifying informationaspossible(location,dates,presenters,sponsors,titles). 4.Eithercolororblackandwhitephotographsmaybesubmittedwiththemanuscript.Colorproducesthebestprintreproduction quality,butpleaseavoidexcessiveuseofmultiplecolorsandshading.Digitalgraphicformats(JPG,GIF,BMP)andMSWord photofilesarepreferred.Printsofphotographsareacceptable.PleasedonotsendphotosembeddedinPowerPoint.Images submittedonslides,negatives,orcopiesofX-rayfilmwillnotbepublished.Forclarity,pleasemarkthetopofeach photographicprintontheback.Tapecaptionstothebackofphotosorsubmitthemonaseparatesheet.Ensurecaptionsand photosareindexedtoeachother.Clearlyindicatethedesiredpositionofeachphotowithinthemanuscript. 5.Theauthorsnames,ranksoracademic/certificationcredentials,titlesorpositions,currentunitofassignment,andcontact informationmust beincludedonthetitlepageofthemanuscript. 6.Submitmanuscriptsto: EDITOR ,AMEDDJ OURNAL ATTN :MCCSDT 2423FSH-H OOD ST F ORT SAM H OUSTON,TX78234-5078 DSN471-6301 Comm210-221-6301 Email:amedd.journal@amedd.army.mil