Citation
U.S. Army Medical Department journal

Material Information

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

Subjects

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

Notes

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

Record Information

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

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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July – September 2014 Perspectives 1 MG Steve Jones; COL Mustapha Debboun; Richard Burton The Growing Challenges of Vector-Borne Diseases to Regionally-Aligned Forces 6 COL Leon L. Robert, Jr; COL Mustapha Debboun Mosquito Biosurveillance on Kyushu Island, Japan, with Emphasis on Anopheles 11 Hyrcanus Group and Related Species Leopoldo M. Rueda, PhD; Benedict Pagac; Masashiro Iwakami; et al High-Throughput Vector-Borne Disease Envi ronmental Surveillance by Polymerase 21 Chain Reaction According to International Accreditation Requirements Marty K. Soehnlen, PhD, MPH; CPT Stephen L. Crimmins; Andrew S. Clugston, MS; et al Evaluation of a Rapid Immuno diagnostic Rabies Field Surv eillance Test on Samples 27 Collected from Military Operations in Africa, Europe, and the Middle East Kristen M. Voehl, DVM, MPH, DACVPM; LTC Greg A Saturday Trends in Rates of Chronic Obstructive Condit ions Among US Military Personnel, 2001-2013 33 Joseph H. Abraham, ScD; Leslie L. Clark, PhD; Jessica M. Sharkey, MPH; Coleen P. Baird, MD, MPH Department of Defense Participation in the Department of Veterans Affairs Airborne 44 Hazards and Open Burn Pit Registry: Process, Guidance to Providers, and Communication Jessica M. Sharkey, MPH; Deanna K. Harkins, MD, MP H; Timothy L. Shickedanz; Coleen P. Baird, MD, PhD Coinfection of Mycoplasma Pneumonia with Chronic Q Fever in a Nurse Deployed to 51 Operation Iraqi Freedom: A Case Study LTC Paul O. Kwon; Jason R. Pickett, MD Over the Ear Tactical Communicatio n and Protection System Use by a 55 Light Infantry (Airborne) Brigade in Afghanistan MAJ Leanne Cleveland Health Hazard Assessment and the Toxicity Clearance Process 59 Mohamed R Mughal, PhD; John Houpt; Timothy A. Kluchinsky, Jr, DrPH Chemical and Biological Warfare: Teaching the Forbidden at a State University 61 CDR (Ret) David M. Claborn, USN; Keith Payne, PhD An Introduction to Public Health Law for Leaders and Clinicians 68 Joseph Baar Topinka, JD, MHA, MBA, LLM The Public Health Specialist Program at th e Medical Education and Training Campus 72 MAJ M. G. Colacicco-Mayhugh; LT Carl Blaesing, USN; LTC Kent Broussard Using the Army Medical Cost Avoidance Mode l to Prioritize Preven tive Medicine Initiatives 76 Cindy Smith; Kelsey McCoskey, MS; MAJ Jay Clasing; Timothy A. Kluchinsky, Jr, DrPH Managing Public Health in the Army Through a Standard Community 82 Health Promotion Council Model Anna F. Courie, RN, MS; Moira Shaw Rivera, PhD; Allison Pompey, DrPH, CPH Performance Excellence: Using Lean Six Sigma Tools to Improve the US Army 91 Behavioral Health Surveillance Process, Boost Team Morale, and Maximize Value to Customers and Stakeholders Eren Youmans Watkins, PhD, MPH; Dave M. Keme ter, MBB; Anita Spiess, MSPH; et al FORCE HEALTH PROTECTION: THE PROVEN FORCE MULTIPLIER

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July – September 2014 The Army Medical Department Center & School PB 8-14-7/8/9 Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx A Professional Publication of the AMEDD Community The Army Medical Department Journal [ISSN 1524-0436] is published quarterly for The Surgeon General by the AMEDD Journal Office, USAMEDDC&S, AHS CDD 3599 Winfield Scott RD STE B0204, JB SA Fort Sam Houston, TX 78234-4669. Articles published in The Army Medical Department Journal are listed and indexed in MEDLINE, the National Library of Medicine’s premier bibliographic database of life sciences and biomedical information. As such, the Journal’ s articles are readily accessible to researchers and scholars throughout the global scientific and academic communities. CORRESPONDENCE: Manuscripts, photographs, official unit requests to receive copies, and unit address changes or deletions should be sent via email to usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil, or by regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301 DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional information to expand kn owledge of domestic & international military medical issues and technolo gical advances; promote collaborative partnerships among Services, components, Corps, and specialties; convey clinical and health service support information; and provide a peer-reviewed, high quality, print medium to encourage dialog ue concerning healthcare initiatives. Appearance or use of a commercial product name in an article published in the AMEDD Journal does not imply endorsement by the US Government. Views expressed are those of the author(s) and do not necessarily reflect official policies or positions of the De partment of the Army, Department of the Navy, Department of the Air Force, Department of Defense, nor any other agency of the US Government. The content does not change or supersede information in other US Army Publications. The AMEDD Journal reserves the right to edit all material submitted for publication (see inside back cover). CONTENT: Content of this publication is not copyright protected. Reprinted material must contain acknowledgement to the original author(s) and the AMEDD Journal OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical Department units and organiza tions, other US military medical organizations, and members of the worldwide professional medical community. LTG Patricia D. Horoho The Surgeon General Commander, US Army Medical Command MG Steve Jones Commanding General US Army Medical Department Center & School Administrative Assistant to the Secretary of the Army GERALD B. O’KEEFE 1411106 By Order of the Secretary of the Army: Official: Raymond T. Odierno General, United States Army Chief of Staff DISTRIBUTION: Special

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July September 2014 1 Perspectives COMMANDERS INTRODUCTION MG Steve Jones Baron Von Steuben introduced Force Health Protection to the United States Army at Valley Forge when he in structed regimental commanders that the preservation care. Captains, lieutenants, and ensigns were given ad ditional instructions on their role in supporting this new leadership responsibility. The concept has served the Army well since its introduction, and, with improved vival rates and lower disease and nonbattle injury rates Joint Publication 4-02 as Measures to promote, improve, or conserve the be havioral and physical well-being of Service members ness, and protect the force from health hazards. 1(pGL-7) Among other things, an October 31, 2006 change added a chapter on Force Health Protection with subor Casualty Prevention, which includes all measures taken by commanders, leaders, individual military personnel, and the healthcare system to promote, improve, or con serve the mental and physical well-being of military per and detailed in Joint Publication 4-02 are Preventive Medicine, Health Surveillance, Combat and Operational Stress Control, Preventive Dentistry, Vision Readiness, and Laboratory Services. Military Medicine 2 COL Ron Bel lamy stimulated critical thinking about our approach to combat casualty care. He stated: Given optimal circumstances, such as in Vietnam, neither the application of sophisticated technologies designed to improve survival of traumatized patients in surgical in tensive care wards or operating rooms, nor greater suc cess in managing the common causes of postoperative deathsepsis and multiple organ failurewill have a Rather, he insisted that improvement would come with a emphasis was realized with implementation of the Com taught Soldiers to apply tourniquets, open airways, and decompress a tension pneumothorax, and issued them ers their role in casualty management and evacuation. advances in Force Health Protection contributed to sig body armor with an increased area of coverage and great er ballistic protection decreased the incidence of thoracic bat Shirt, Advanced Combat Helmet, and ballistic eye protection also provided additional personal protection. the improvised armor added to vehicles by units early in Each of these advances enhanced Soldier survivability. es such as improved surveillance for biological weap ons, the human dimension of Force Health Protection deserves further attention. Just as critical thinking about combat casualty care, critical thinking about the human their numbers. My analysis of casualties as Command showed that service members were at greater risk of of command, they prompted the Secretary of Defense to question whether shorter but more frequent tours in The Defense Advanced Research Projects Agency sub sequently commissioned a study to identify critical fa tality time periods, training, information, and equipment gaps. diers and subject matter experts. They found that nearly ployment, most often attributed to a lack of experience. FORCE HEALT H PROTECTION AND T H E HUMAN DIMENSION High mobility multipurpose wheeled vehicle Mine resistant ambush protected vehicle

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2 http://www.cs.amedd.army.mil/amedd_journal.aspx EDITORS PE RS PE CTIV E As a new century moves through its second decade, the world continues to present increasingly perplexing and dangerous challenges for stability and freedom. Threats locating, shifting into different forms, and spreading. Military operations planners try their best to anticipate the nature and locations of these threats, and design strategies and doctrine to best counter them. A common thread across all planning is the certainty that future op erations will continue to encounter serious threats un related to an anticipated military opponent, especially in undeveloped, remote areas throughout the world. Debboun address the variety and breadth of the threat posed by vector-borne diseases and how Army medical planners must tailor their efforts to support the regionalalignment model of building combat capacity and capa bility. Although the US military has an extensive, worldwide infrastructure involved in disease surveillance and research, experience has shown that there continue to be gaps in data and information about resources for many locations where military operations may be required. This article discusses how those existing capabilities may take advantage of any locally-based resources, and the requirements for planning to work closely with other US and foreign government organizations, as well as nongovernmental organizations which are providing services in the regions. As with the military threats mentioned above, the vectors that carry dangerous pathogens themselves appear, disappear, change, and spread, an increasingly serious problem in this modern world of ubiquitous modes of transportation. Current, accurate data concerning the concern are vital to those planning medical support for military operations. An example of the commitment and effort involved in gathering and maintaining such data is presented by Dr Leopoldo Rueda and his colleagues. Their article describes a biosurveillance project targeting mosquito species on the southern Japanese island of PERSPECTIVES Loss of local intelligence when an old unit leaves and a lack of familiarity with the environment and enemy tactics were also cited as contributing factors. A second spike in fatalities occurred at the 6-month point in the tour which Soldiers attributed to complacency. A minor spike in Soldier fatalities noted at the 10-month mark was attributed to fatigue, complacency, and stale tactics. The US Army Human Dimension Concept provides a framework to address the human factors of Force Health Protection. A better understanding of the cognitive, physical, and social components may lead to improve ments in training and better communication of success ful tactics, techniques, and procedures. Learning, train ing, repetition, and practice all affect cognition and the ing and compress the time it takes to accumulate experi ential competence may shorten the high risk period early in a tour. Physical factors such as fatigue, sleep depriva tion, dehydration, hunger, and stress from heat or cold affect decision-making in combat. Psychological factors including complacency, stress, boredom, motivation, and a sense of isolation affect decision-making as well. Recognition of these factors and actions to mitigate their the onset of fatigue. A reduction in the use of energy drinks and long hours playing video games after mis sions will lead to better sleep, and more rested Soldiers. relationships, and good communication with others will produce Soldiers who are more resilient and resistant to stress. Application of the Human Dimension Concept has great potential for not only enhancing performance, jury and illnessthe goal of Force Health Protection. RE F E R E NC E S 1. Joint Publication 4-02: Health Service Support Chiefs of Staff; July 26, 2012. Available at: http:// 2. Bellamy RF. The causes of death in conventional land warfare: implications for combat casualty care research. Mil Med 3. Plank T, Scheff S, Sebok A. First 100 days of deployment critical to soldier survivability. Na tional Defense [serial online]. May 2010. Avail able at: http://www.nationaldefensemagazine.org/ archive/2010/May/Pages/First100DaysofDeploy mentCriticaltoSoldierSurvivability.aspx. Accessed Projects Agency; April 2010. Available at: http:// www.manprint.army.mil/documents/2010/Scott_ TRADOC Pamphlet 525-3-7: The U.S. Army Hu man Dimension Concept Fort Eustis, VA: US Army Training and Doctrine Command; May 21,

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July September 2014 3 importance. The article provides a detailed look at a biosurveillance project: the precollection research to better target collection areas; the multiyear collection effort itself; and the extensive work required to identify the collected specimens and then analyze the results against historical data. Determination of the presence of pathogens among col lected specimens of potential vectors is the critical step in the surveillance of an area to plan countermeasures against diseases. Such testing can be time consuming, and sometimes can only be performed at a laboratory distant from the area of concern. Dr Marty Soehnlen, CPT Stephen Crimmins, and their colleagues developed a method of standardized testing of surveillance samples using polymerase chain reaction methods which pro vides high-throughput and allows analysis of multiple pathogens from the same sample. They developed tests dards which can be performed at the US Army Public Health Command Region Europe Laboratory Sciences laboratory, but have universal Department of Defense application. Their detailed report should be of great in terest to all those charged with providing surveillance of vector-borne diseases throughout not only military re sources, but all other government disease management agencies as well. Throughout most of recorded history, rabies has been been a target for treatment and elimination from the dawn of medical science, yet today it is still present on every of mammals, both feral and domesticated, in rural and urban environments. Although infections in humans is relatively rare in the United States, rabies poses a con stant threat to military personnel involved in all types of deployed settings. As such, prompt and reliable iden Voehl and LTC Greg Saturday have contributed an arti cle describing a research study in which they evaluated a commercially available test kit which can be used in aus The results of their study, combined with that of their lit erature review, could result in another important tool for medical support units charged with protecting our troops from diseases and other environmental hazards. Respiratory health has received increasing attention from researchers over the last century or so, as the rela tionship of damage to airborne hazards in the workplace, smoking, and general air pollution has been proven and publicized. Military personnel can be exposed to a complex array of potential hazards and pollutants, sometimes highly concentrated, but more often present in lower concentrations which become an unnoticed, ever-present part of the environment. The Persian Gulf Dr Joseph Abraham and his colleagues conducted an extensive, detailed study of medical treatment records concerning chronic obstructive pulmonary disease and associated conditions for active duty military personnel across the 13-year period of current combat operations in the Middle East and Afghanistan. They were seeking information on rates of the conditions, trends, and char Their article is a clear description of the extensive data collected, the detailed data reduction performed, and the careful analysis of that data. The data is presented clearly and logically throughout the article. Some of the results were unexpected, others are not readily explain of research into respiratory health of our military per sonnel, and should generate further investigations. ratory health of military personnel who have served in 2012. That language directs the Department of Veterans Affairs to establish a registry to collect information re garding all potential exposures experienced by military personnel during deployments that might adversely af fect their respiratory health. The article provided by Jes sica Sharkey et al presents an excellent description of the purpose and parameters of the registry which is slated the eligibility criteria and registration process for those wishing to enter the registry. There is also important information for military healthcare providers regarding the military healthcare systems perspective, responsi bilities, and obligations to those requesting clinical as sessments as part of the registration. This article is an excellent heads up for participants and caregivers alike concerning the impending availability of an important new aspect of healthcare for those who have served. As has been noted in the pages of the AMEDD Jour nal time and again, military healthcare providers in deployed environments must always expect the unex Jason Pickett relate such a situation in their excellent case study of a patient whose symptoms and diagnostic

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4 http://www.cs.amedd.army.mil/amedd_journal.aspx indications were varied and complicated. She was even tually diagnosed as having Q fever, which was present as a coinfection with mycoplasma pneumoniae a com bination rarely addressed in medical literature. Further, she had no history of the typical risk factors associated with Q fever during her deployment. This article is a well-organized, detailed, and complete; a superb exam ple of medical professionalism at its best. Over the last 6 years, the Army Hearing Program has been addressed in several Journal articles, beginning with its conception, its implementation among garrison units, and how it was adopted in the deployed, combat turns with an article that provides, among other things, an update on the level of understanding of the importance of hearing protection at the individual Soldier level, and how many have tested different hearing devices in combat, sometimes obtained at their personal expense. As part of the returning Soldier health assessments, she conducted a survey of returning troops to quantify their opinions of effectiveness of protective devices, as well concerning protective devices to be collected from those who very recently experienced actual combat rather than a simulated test environment. The results of the surveys were then compared to the preand postdeployment au diograms to determine any correlation between those reporting use of protective devices, and those who did not. The information in this article should be of value to researchers, designers, and testers of protective hearing devices for the military, which will have broad civilian application as well. The safety of the end user has long been a concern for the Army formally established the Health Hazard As sessment Program, which had been operating under The evaluate and monitor development and procurement of all Army materiel systems, including weapons, equip ment, clothing, etc. As manufacturing processes and the materials used have become more sophisticated and complex, the potential for toxicity in resulting products to have harmful effects on humans and other living things has become an ever more important factor. This is addressed by the Armys Toxicity Clearance process which is detailed in the article by Dr Mohamed Mughal and his coauthors. They describe the formal investigative and clearance requirements involved for a manufacturer materials in products before introduction into the Army supply system. This is an interesting look at another im portant function performed by AMEDD professionals, largely in the background, that is vital to protecting the health of our Soldiers every single day. History is replete with examples of best-intended, con sensus actions proving fruitless because someone does laws, treaties, pronouncements, and unilateral actions have been intended to eliminate chemical and biological weapons, with the inevitable result that those weapons continue to exist under control of the most dangerous of lawless regimes and tyrants. However, since the notion that the problem was solved was conveyed by the coop erating governments, interest in those weapons waned truly knowledgeable in chemical and biological warfare number of events over the last 30 years has exposed and reestablished the vital need for this area of expertise. Payne describe a fellowship and graduate program of offered by Missouri State University in cooperation with area. This is an important and very informative article about a proactive approach to dealing with a real-world this threat will likely not be truly eliminated any time soon, if ever. Regular readers of the AMEDD Journal are familiar with MAJ (now retired) Joseph Topinkas contributions, along with those of his colleagues, of excellent articles focused on various legal topics and considerations spe has submitted an article providing an overview of public health law. This article is written as an introduction for military medical personnel and other leaders to convey the breadth and depth of legal considerations that per the reader begins to understand how integral and impor tant a basic understanding of the law is to successfully functioning in the various areas of public health. Realignment and Closure Commission recommenda tions was the consolidation of all enlisted basic and most specialty medical training into a single Medical Education and Training Campus (METC) at Fort Sam Houston, Texas. The METC became fully operational in September 2011. One of the consolidated specialty areas taught at METC is the Public Health Specialist Program, which graduates Army and Navy Preventive Medicine Specialists and Technicians (respectively). PERSPECTIVES

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July September 2014 5 MAJ Colacicco-Mayhugh and her coauthors have pro vided a detailed description of that program, and how it has already been revised to optimize both resources and schedule based on initial experience teaching a multi service curriculum. Their article provides excellent in sight into the dedication and high level of expertise and professionalism that is involved in the design, delivery, evaluation, and revision cycle necessary to ensure that students receive only the best training possible. The future health and readiness of many military members may directly depend on the knowledge and skills im parted to these new Soldiers and Sailors. Throughout history, militaries have always faced the Gordian knot of how to satisfy the ever increasing re quirements their governments/leaders place on them, while simultaneously receiving ever decreasing resourc es with which to accomplish those tasks. Todays envi ronment is no different. Politics, economic factors, shift ing priorities, new and resurfacing threats, and many a share of those funds can be intense. Usually that com petition hinges on the value to the organization realized from the committed funding, the classic return on in personnel costs does not cover all of the categories af fecting the true amount of medical costs, thus degrading the suitability of the data for use in evaluating preven tive medicine program initiatives. Cindy Smith and her coauthors have provided a detailed description of a tool programs. This excellent article is, in essence, a tutorial for use of the analysis tool, clearly explaining the process in a straightforward manner. This powerful analysis tool should be of great interest and utility to all preventive medicine program developers in Army medicine. es to large scale disasters have increasingly focused on the apparent disorganization and inability to coordinate within and among government organizations involved complexity of public health systems of virtually every scale, even the seemingly benign and routine function ing within a military installation. As Anna Courie and her coauthors clearly describe, the public health sys tems in both the civilian communities and on military installations share the same characteristic of dependence on various, distinct resources and components which are themselves responsible to disparate organizations and authorities. This fragmented structure wastes resources, causes confusion, is error prone, and is obviously slow and ponderous in functioning and reacting to public health issues. The Army has adopted a structure across its installations called the community health promotion council (CPHC) to manage the Army Public Health Sys tem. The Army Public Health Command has established a standard model for the CPHC to ensure a coordinated approach to managing public health responsibilities and functions. The standard CPHC has been implemented in 12 of the larger Army installation in the United State, received the additional resources necessary to adopt the standard model. Ms Courie et al investigated the rela tive effectiveness of the public health systems aboard installations with standard CPHC processes versus those without the features of the standard model. Their well-researched article carefully develops the founda tion for the CPHC approach, and details the results of their study. This is an interesting, informative look at the complexity and broad range of concerns, both tangible and perceptive, that are involved in managing an effec tive public health system. Lean Six Sigma (LSS) is a well-known process improve ment, problem-solving methodology that is used by activities within the US Army, including those within AMEDD. Although best known for its success within business and manufacturing, it has also proven valu able in use with knowledge-based processes. Dr Eren public health surveillance function within the Armys cally the report of the suicide behavior surveillance data. Their article clearly details the application of the LSS methodology as a carefully designed, step-by-step pro parameters, analyze the data, determine the points of substandard performance and the causes, develop and imcorporate changes to improve the processes, and measure and document the resulting performance. For this project, the total number of labor hours (baseline) mined that a quarterly report was not seen to be neces sary by its users, so the report is now produced annually, resulting in additional savings. This article presents an excellent introduction to LSS for those unfamiliar with process reveals much room for improvement once the

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx Global factors are interacting together to fundamentally change the worldwide vector-borne disease threat and the corresponding public health landscape. These chal lenges are predicted to become increasingly problematic threat of emerging and reemerging vector-borne dis eases will certainly present an increasing challenge for military entomologists and public health professionals. increasing demands on regionally-aligned US forces in and resource consumption. from squad to corps level. 1 The changing strategic envi conditions in an effort to align forces regionally to spe forces will require intimate integration with regional al to increase specialized regional expertise and cultural awareness so US forces will be better prepared to meet present and future regional requirements. Through the responsive and regionally engaged. continue to face numerous challenges from vector-borne diseases. Not only must military healthcare systems continually adapt to emerging and re-emerging diseases ing countries that either cannot or will not address con tinuing high mortality from infectious diseases. 2 These ernments will increasingly rely on regionally-aligned US forces to assist and manage unexpected healthcare and training to cope with uncertainty and complexity The Growing Challenges of Vector-Borne Diseases to Regionally-Aligned Forces ABSTR A CT on regional alignment. The continuing threat of vector-borne and other infectious diseases will present growing organizations will enable US forces to respond and engage more effectively and appropriately to accomplish

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July September 2014 7 in military preventive medicine and public health as it relates to infectious disease surveillance and control. 3 CH A LL E NG E S AH EA D United States forces will continue to face challenges in global engagement. The challenge to force health pro The problem that faces the joint force is to determine how to more effectively provide health protection to a force that will operate in a complex and diverse opera tional environment; confront a range of traditional and new adversaries and threats; employ and integrate new The importance of this problem statement is reinforced tion who warns that emerging diseases have become a much larger menace in a world characterized by high mobility and unstable economies. worldwide. armies and changed the course of military operations. ger the main causes of morbidity and mortality among tious diseases continue to be an important threat to US forces both in the United States and worldwide. 6 tor control has lessened the effects of some vector-borne while others such as malaria and dengue fever remain a military concern and new potential threats continue to for example. 7 ness of armed forces continues to rely heavily on vec diseases may again have the same devastating effect on service member health and military readiness as they did in the past. TH E GLOB A L CH A LL E NG E OF VE CTORBORN E DIS EA S E S The global challenge of infectious diseases cannot be 8 animals and people. Because of the increasing threat of 8 Numerous publications and al change and vector-borne diseases and have provided 9-11 Vector-borne diseases account for 17% of the estimated global burden of all infectious diseases. 12 9 and onchocerciasis. 11 mated 390 million dengue infections each year in over severe public health problems worldwide. It is a leading cause of death and disease in many developing coun 11 mental changes such as climate change and urbaniza tion are causing vectors and vector-borne diseases to is facing a severe shortage of entomologists and vec tor control experts. 11 entomology programs at the undergraduate university and treatment. This has resulted in the silent increase in

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8 http://www.cs.amedd.army.mil/amedd_journal.aspx vector-borne disease morbidity and mortality in these areas. These realities will place increased burden on re gionally-aligned US forces as they engage and reengage with regional allies and threats. to surveillance and control of zoonotic and vector-borne cially the most daunting challenges in megacities. The number of these megacities with populations in excess of These phasis to eliminate insect vectors and control associated pesticides to more integrated and sustainable approaches. These integrated approaches must include sound envi minimal reliance on routine pesticidal spraying. 11 DOD FORC E HEA LTH PROT E CTION FOR RE GION A LLY-ALIGN E D FORC E S guidance highlights the need for improving joint warf forces. 16 4 was published as 17 rigorous assessment and analysis of force health pro tection-related capabilities through analysis of existing for appropriate materiel and nonmateriel solutions to be capabilities. ing of infectious disease trends and characterization that diagnostic laboratories. The full and appropriate use of these diagnostic facilities will certainly necessitate advanced training of military preventive medicine per sonnel so they fully understand the requirements and capabilities of rapid diagnostic labs. research and surveillance laboratories. There are Na located in rural Thailand and Nepal. The missions of these laboratories include prevention of psychiatric increase the operational readiness of forward-deployed service members. The overseas laboratories continuously conduct disease emerging infectious diseases that could affect the US military. This mission is accomplished by orchestrat ercises. Because overseas laboratories interact with host nation medical systems at national and local levels on a operating in the region; so they must understand how to effectively interact with these diverse organizations. is essential. The provincial reconstruction teams part tegic Plan is an example of implementing the planning considerations for foreign internal defense missions that will also apply in future regionally-aligned missions. 3 traditional military operational or training environments. clude not only traditional military preventive medicine and sanitation topics but be expanded to include country THE GROWING CHALLENGES OF VECTOR-BORNE DISEASES TO REGIONALLY-ALIGNED FORCES

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July September 2014 9 ing courses and programs. New training opportunities must be afforded military preventive medicine person nel to familiarize them with how to interact with and partners. This training should start with initial entry training and be a continual process. A GLIM P S E INTO TH E FUTUR E? platform for combating vector-borne diseases. The strat egy is based on the premise that effective control is not the sole responsibility of the health sector but of a wide pacity building. The ultimate goal is to prevent the trans 18 It has been recently suggested and sustainable vector control in Southern Sudan and an 19 healthcare system facing a huge burden of several vec tor-borne diseases. 20 derstanding of spatio-temporal patterns of vector-borne diseases and complicating factors that incorporates and tor control program. be slow and will require a sustained national and in 21 and imple malaria control infrastructure. 3 This mission required a and economic realities is essential in South Sudan as a case study for future contingency tion and control of vector-borne diseases when engaging and assisting regional international and national part ners and allies. SUMM A RY emerging vector-borne diseases. These diseases will have increasingly negative effects on human health in developing countries and growing mega-cities. The challenges will require traditional preventive medi health protection doctrine and training must continually adapt to these future challenges. RE F E R E NC E S 1. Army News Service 2014.

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10 http://www.cs.amedd.army.mil/amedd_journal.aspx 2. US Army Med Dep J. 3. military entomologists in stability and counterin surgency operations. US Army Med Dep J. 4. Force Health Protection Concept of Operations (CONOPS) Public Health in the 21st Century: Opti mism in the Midst of Unprecedented Challenges 6. zoonotic and vector-borne diseases in US military 1269. 7. The past and present threat of vector-borne dis eases in deployed troops. Clin Microbiol Infect. 8. 9. bility to vector-borne diseases. Clin Microbiol Rev. 10. Vector-borne Diseases: Un derstanding the Environmental, Human Health, and Ecological Connections. 11. A Global Brief on Vector-Borne Diseases Ge 12. sanitation and health. J Water Health 13. mate change and infectious diseases in megacities Health in Megacities and Urban Areas 14. World Urbanization Prospects: The 2003 Revision 2014. es to vector control. Bull World Health Organ 16. Joint Force Health Protection Concept of Opera tions. 2007. 17. Health Readiness Concept of Operations (CONOPS) 18. 19. vector-borne diseases in South Sudan. Malar J. 20. 21. AUTHORS Army Medical De partment Journal THE GROWING CHALLENGES OF VECTOR-BORNE DISEASES TO REGIONALLY-ALIGNED FORCES

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July September 2014 11 Mosquito-borne disease agents can pose a threat to hu mans, particularly to deployed troops, both in foreign environments and, if imported, domestically. Gaps exist in the fundamental knowledge regarding mosquito vec in subgenera Anopheles Aedes and Culex from central Japan. These 3 subgenera include major vector species that are responsible for transmitting malaria, dengue, Japanese B encephalitis, as well as other pathogenic mi croorganisms in many parts of the world, particularly in Asia. Anopheles Hyrcanus Group consists of several mosquito-borne diseases in the Oriental and Palearc tic regions. Currently, about 30 species have been de scribed and named. 1-3 In 2004, about 27 species were listed in the Hyrcanus Group, with 6 species placed in the Lesteri Subgroup, 4 in the Nigerrimus Subgroup, and 17 in the unassigned subgroup. 3 In their 2013 review of the malaria vectors in the Greater Mekong subre gion, Hii and Rueda 4 created the new Sinensis Subgroup that contains those previously unassigned species ( An. sinensis Wiedemann, An. pullus Yamada, other 6 spe cies). Recently, there is more focus on Anopheles Hyr canus Group in Asia, primarily to clarify the taxonomy of the species complex and to update the distribution records of vectors and related species. 4-10 Although sev eral Anopheles mosquito publications exist, they were not updated to include recent discoveries, taxonomic re cords, and related pertinent collection data from central Japan. 11-14 In 2005, Rueda and others 5 of An. Hyrcanus Group occurring in Japan, namely: An. sinensis An. engarensis Kanda and Ogama, An. yatsu shiroensis Miyazaki, An. sineroides Yamada, and An. lesteri Baisas and Hu. In 2013, Imanishi 15 recorded for An. belenrae Rueda from Hokkaido, Japan. Anopheles pullus and An. kleini Rueda, the primary ma laria vectors in South Korea, have never been collected in Japan. 16 Known and potential vectors of malaria in the Hyrcanus Group include An. sinensis An. lesteri An. belenrae An. kleini and An. pullus 16 The purpose of our study was to strengthen mosquitoborne disease biosurveillance capability in Japan by ac as having taxonomic and ecological importance, thereby enhancing the knowledge base associated with poten tial malaria vectors, and incorporating this information as a component of already in-place mosquito surveil lance programs, including the Walter Reed Biosystemat ics Units VectorMap/MosquitoMap, and the US Army mosquito surveillance training programs. MA T E RI A LS A ND ME THODS Mosquito Field Collection and Identification Specimen collections were conducted from 2006-2013 from various areas within Kumamoto, Fukuoka, Saga and Nagasaki Prefectures, on Kyushu Island, Japan (Figure 1). Additional specimens were previously col lected by Dr Motoyoshi Mogi from 1984-2005 from localities in Saga and Nagasaki Prefectures. These pre fectures were selected because the taxonomic records Mosquito Biosurveillance on Kyushu Island, Japan, with Emphasis on Anopheles Hyrcanus Group and Related Species (Diptera: Culicidae) Leopoldo M. Rueda, PhD Yukiko Higa, PhD Benedict Pagac, BS Kyoko Futami, PhD Masashiro Iwakami, BS Nozomi Imanishi, MS Alexandra R. Spring, MS MAJ Lewis S. Long, MS, USA Maysa T. Motoki, PhD COL Mustapha Debboun, MS, USA James E. Pecor, BS ABSTR A CT This report includes the distribution records of the Anopheles ( Anopheles ) Hyrcanus Group and associated spe Kumamoto, Nagasaki, Saga), primarily from 2002-2013. The status of common and potential mosquito vectors, particularly Anopheles species, in Japan are noted.

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx for the Anopheles Hyrcanus Group were unclear or reported and described species from this region. The Hyrcanus Group includes all known malaria vector species in Japan 5,14 and it is essential to clarify the taxonomy of the group, including geo graphic distribution records of the group species. paper follows that of Knight and Stone. 19 Depending on the habitats (rice paddies, irrigation ditches, permanent and temporary pools, other standing water areas (Figures 2 and 3)), larvae were collected using a standard larval dipper (350 ml, 13 cm diameter) or a white plastic larval tray (25204 cm) (BioQuip, Rancho Dominguez, CA). Each habitat within a location was surveyed for up to one hour or until about 100 larvae were col lected. The latitude and longitude of each location was recorded using a hand-held global positioning system (GPS) unit (Garmin International, Olathe, KS) set to the WGS84 datum. Sampling locations were photographed using a digital camera to assist in verifying the accuracy of the habitat description. MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE) 33.9 33.4 32.9 32.4 31.9 31.4 30.9 128.5 129 129.5 130 130.5 131 131.5 132 Longitude (degrees) Latitude (degrees) Figure 1. Mosquito collection sites on Kyushu Island (right) and Fu kue Island (left), Japan. Figure 2. Larval habitats of Anopheles ( Anopheles ) species in the Nagasaki Prefecture, Kyushu Island: (A) rice paddies with ter races, with closeup of rice seedlings; (B) rice paddy, with closeup of rhizobium rice plants; (C) irrigation ditch; (D) drainage ditch, partially covered by dried grasses (Fukue Island); (E) water well. A B C D E

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July September 2014 13 Collected larvae were placed in plastic Whirl-Pak bags (118 ml, 818 cm) (BioQuip, Rancho Dominguez, CA) lection site. The Whirl-Pak was then tightly closed to retain air, placed in a cooler, and brought to the labora tory where the larvae were directly preserved in 100% larvae were individually link-reared to adult stage, as morphological voucher specimens for this work (Figure 4). Emergent adults were pinned on paper points, each diagnostic morphological characters (Figure 5). DNA Isolation and Sequencing from individual larvae, pupae, and adults (1 or 2 legs per adult) by phenol-chloroform extraction, and the PCR quencing were carried out using standard protocol. 17 A ers 5.8S (5-ATCACTCGGCTCGTGGATCG-3) and 28S (5-ATGCTTAAATTTAGGGGGTAGTC-3). 18 The PCR products were directly sequenced using Big Dye 3.0 (Applied Biosystems, Inc (ABI), Foster, CA) with an ABI 3100 sequencer. Sequences were edited using Sequencher ( V 4.8, Gene Codes Corporation, Ann Arbor, MI) and aligned in Clustal X.Sequences of An. Hyrca nus Group species ( An.sinensis An. lesteri ) are those of previous studies using the primers therein. 17,18 Voucher specimens and collection records will be deposited in the US National Museum of Natural History (US NMNH) of the Smithsonian Institution, Suitland, MD. RE SULTS The summary of collection localities and larval habitats for Anopheles species (primarily An. sinensis and An. lesteri ) from 4 prefectures (Fukuoka, Kumamoto, Na gasaki, Saga) of Kyushu Island, Japan, are presented in the Table (page 18). The map of Kyushu, with collec tion sites of mosquitoes, is shown in Figure 1. Prior to 2013, larvae of An. sinensis were collected from various habitats either alone or in association with the following Aedes or Culex species: Cx. ( Culex ) tritaeniorhynchus drainage areas, ground pits or depressions) in Nagasaki and Kumamoto Prefectures. Aside from An. sinensis no Anopheles species were collected from any larval habi tats in association with Aedes or Culex species. In 2013, A B C D E Figure 3. Larval habitats of Anopheles ( Anopheles ) species on Kyushu Island: (A) stream margin with small pool (arrow) (Kuma moto Prefecture); (B) stream margin with small water pockets (arrow) (Kumamoto Prefecture); (C) river margin with water pockets grasses (Nagasaki Prefecture).

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14 http://www.cs.amedd.army.mil/amedd_journal.aspx MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE) A B C D Figure 4. (A) Emergence plastic vials for rearing mosquito larvae and pupae. (B) Newly emerged adult male Anopheles mosquito. (C) Collected Anopheles Hyrcanus Group larvae showing diverse morphology. (D) Anopheles Hyrcanus Group larva, fourth instar, dorsal view. Figure 5. (A) Pinned adult mosquito specimens for deposition in the WRBU, Smith sonian Institution, National Mosquito Collections. (B) Pinned adult female of Anopheles belenrae lateral view. A B

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July September 2014 15 ing molecular sequences) were also found in association with the following: Cx. ( Cux. ) tritaeniorhynchus Cx. ( Cux. ) spp.; Ae. ( Finlaya ) spp.; Ae. ( Ochlerotatus ) spp. in rice paddies and irrigation ditches in Nagasaki Prefec ture (Isahaya, Moriyama, Obama-Unzen, Onakao). During the 2013 survey of various localities in Kyushu Island, the rice paddies where we collected the larvae and pupae of Anopheles Hyrcanus Group had water pH ranging from 6.68-8.61 (mean, 7.77), millivolt age (175.00-237.00 mV; mean, 215.10) and temperature (30.50C-32.80C; mean, 32.10C). Other water habitats (irrigation ditches, ponds, stream margin, pools, and drainage) that were positive for Anopheles larvae and pupae also exhibited variable pH, mV, and temperatures. Culicine mosquitoes (nonanophelines) collected from Kyushu Island in 2013 included Ae. ( Fin. ) japonicus tainers, shrine stone bowls); Ae. ( Fin. ) togoi (Theobald) from Isahaya (pond); Ae. ( Ste. ) albopictus (Skuse) from ditches, shrine stone bowls, tree stumps or holes, tempo rary seepage); Cx. ( Ocu. ) bitaeniorhynchus Giles from Moriyama (drainage ditches); and Cx. ( Cux. ) tritaenio rhynchus from Moriyama, Obama-Unzen, Hitoyoshi (drainage ditches, irrigation ditches, rice paddies). About 60 mosquito larvae collected from Nagasaki Prefecture in Ae. ( Finlaya ) from Isahaya; Ae. ( Ochlerotatus ) from Nomozaki and Onakao; and Cx. ( Culex ) from Moriyama, Nagasaki, Obama-Unzen, Setoishi, Isahaya, Aikawa, larval specimens of Aedes and Culex together with both larvae and adults of An. Hyrcanus Group from 4 prefec tures, will be completed in the future. COMM E NT Among the Anopheles Hyrcanus Group species, An. pul lus An. sinensis An. lesteri An. kleini, and An. belenrae are known or potential vectors of vivax malaria in the Korean peninsula and other countries. Anopheles sinen sis is the most common anopheline species in Japan, in cluding the Ryukyu Islands. 14 It has long been suspected as the most important vector of malaria in Japan, includ ing Okinawa and Hokkaido. Even though indigenous malaria has disappeared, this vector remains abundant throughout Japan. It is a known vector of malaria in South Korea and China, and it has a wide distribution in Asia. 4,5,8-10,14,20 Anopheles lesteri ( =anthropophagus ) is a very important vector of malaria in China. To clarify and stabilize the taxon, Rueda and others 6 designated and described the neotype and alloneotype of An. lesteri. This species was suspected to be an important vector of indigenous malaria in Japan, particularly in Hokkaido where it commonly occurs in great numbers. It is also common in the Ryukyu Islands and has been found more frequently in coastal regions in Honshu and Kyushu. 14 Anopheles yatsushiroensis is not known as a vector of in digenous malaria in Japan. Anopheles belenrae (Figure 15 is a potential vector of vivax malaria in Korea. 21 Plasmodium berghei An. belenrae adults in South Korea. 22 The morphological details of the head, thorax, abdomen, wings, and legs of An. belenrae are shown in the Walter Reed Biosystematics Units website.* The other Hyrcanus Group species (ie, An. sineroides and An. engarensis ), as well as several Anopheles ( Anopheles ) species ( An. bengalensis Puri; An. koreicus Yamada and Watanabe; An. lewisi Ludlow; An. lindsayi japonicus Ya mada; An. omorii Sakakibara; An. saperoi Bohart and Ingram; An. yaeyamaensis Somboon and Harbach), are not known vectors of indigenous malaria in Japan. Most mosquito collections, including Anopheles spe cies, noted by Tanaka and others 14 in 1979, are presently deposited at the National Institute of Infectious Diseas es (NIID), Tokyo, Japan, where most of the Hyrcanus Group species were examined by author L. M. Rueda during his visit in 2006. In a recent conversation with the authors, Dr Kyoko Sawabe mentioned that there are some possible specimens of An. yatsushiroensis collect ed by Dr M. Otsuru in 1951 and 1964 on Kyushu Island now deposited at the NIID, Tokyo. These specimens should be examined for further morphological and mo lecular analysis to clarify the existence of this species. In 2003, Dr Motoyoshi Mogi inquired to check the type specimens of An. yatsushiroensis from the Department of Parasitology (DP), Faculty of Medicine, Kyushu Uni versity, Fukuoka, Kyushu (reported as the depository of An. yasushiroensis types by Miyazaki 12 in 1951). How ever, Professor Isao Tada (former director of the DP) in formed Dr Mogi that no type specimens existed at the DP. It may be useful to designate neotypes for An. yatsu shiroensis if it is proven as a valid species. Although previous researchers considered An. yatsushi roensis as a synonym of An. pullus they used Korean specimens to obtain their molecular and morphological data. 23,24 However, because the type locality of An. yat sushiroensis is in Japan, it is necessary to do a genetic comparison of An. pullus from South Korea with the if the two are synonyms or not. In 1951, Miyazaki, 12 who http://www.wrbu.org/SpeciesPages_ANO/ANO_A-det/ANbln_Adet.html

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx An. yatsushiroensis provided elaborate morphological descriptions, ecology, and distributions of this species. We did not collect An. pullus during our previous collections from 2002-2008 in Japan, and no report indicates the existence of An. pullus in that coun try. Furthermore, An. pullus is considered a major vec tor of vivax malaria in the Korean peninsula. 16 Through biosurveillance, it is also interesting to investigate if an other major Korean malaria vector, An. kleini is present in Japan. In our attempt to recollect specimens of the Hyrcanus Group, particularly An. yatsushiroensis we recently vis ited numerous localities and conducted extensive larval collections at various habitats in Nagasaki Prefecture and Kumamoto Prefecture (including Yatsushiro City, the type locality of An. yatsushiroensis reported by Mi yazaki 12 ) and neighboring areas from 2006 to 2013. Un fortunately, we were not able to collect samples of An. yatsushiroensis from 2006 to 2012. Although Dr Sawabe mentioned that there are some pos sible specimens of An. yatsushiroensis deposited at the NIID, Tokyo, we have not examined them yet. Further more, more than 200 larvae and adults of An. Hyrcanus Group collected in 2013 from Kumamoto and Nagasaki Prefectures are still being examined and analyzed by morphological and molecular techniques. Molecular data (PCR, sequences) will be reported later, particu larly from the 2013 specimens for possible presence of An. yatsushiroensis and other species in An. Hyrcanus Group on Kyushu Island. ACKNOWL E DG E M E NT This research was performed under a Memorandum of Understanding between the Walter Reed Army Insti tute of Research and the Smithsonian Institution, with institutional support provided by both organizations. We express our sincere appreciation to the follow ing: Dr Motoyoshi Mogi for arranging the visits of Dr Rueda to Saga and Fukuoka Prefectures, his help in mosquito collections, and for sharing his mosquito specimens; CPT Robert Moore and SGT J. Santano for their help in collecting mosquito samples from Ku mamoto Prefecture; Professor Y. Oneda, for his help in collecting samples and guiding us in locating larval habitats in Akagawa and Takegima, Fukuoka Prefec ture and Tosu City, Saga Prefecture. Special thanks go to Dr Noburo Minakawa, particularly for making the arrangements for our visit to Nagasaki, and Dr Kyoko Sawabe for correspondence and invitation to visit and examine the mosquito collections at NIID, Tokyo. RE F E R E NC E S 1. Rueda LM. Two new species of Anopheles (Anoph eles) Hyrcanus Group (Diptera: Culicidae) from the Republic of South Korea. Zootaxa. 2005;941:1-26. 2. Ramsdale CD. Internal taxonomy of the Hyrcanus Group of Anopheles (Diptera: Culicidae) and its bearing on the incrimination of vectors of malar ia in the west of the Palearctic Region. European Mosq Bull 2001;10:1-8. 3. Anoph eles (Diptera: Culicidae): a working hypothesis of phylogenetic relationships. Bull Entomol Res. 2004;94:537-553. 4. Hii J, Rueda LM. Malaria vectors in the Greater Mekong Subregion: overview of malaria vec tors and remaining challenges. Southeast Asian J Trop Med Public Health. 2013;44(suppl 1):73-165, 306-307. 5. Rueda LM, Iwakama M, OGuinn M, Mogi M, Prendergast BF, Miyagi I, Toma T, Pecor JE, Wilk erson RC. Habitats and distribution of Anopheles sinensis and associated Hyrcanus Group in Japan. J Am Mosq Control Assoc. 2005;21(4):458-463. 6. Rueda LM, Wilkerson RC, Li C. Anopheles (Anopheles) lesteri Baisas and Hu (Diptera: Cu licidae): neotype designation and description. Proc Entomol Soc Washington 2005;107(3):604-622. 7. Rueda LM, Ma Y, Song GH, Gao Q. Notes on the distribution of Anopheles (Anopheles) sinensis Wi edemann (Diptera: Culicidae) in China and the sta tus of some Anopheles Hyrcanus Group type speci mens from China. Proc Entomol Soc Washington 2005;107(1):235-238. 8. Rueda LM, Kim HC, Klein TA, Pecor JE, Li C, Sithiprasasna R, Debboun M, Wilkerson RC. Distribution and larval habitat characteristics of Anopheles Hyrcanus Group and related mosquito species (Diptera: Culicidae) in South Korea. J Vec tor Ecol. 2006;31(1):199-206. 9. Rueda LM, Zhao T, Ma YJ, Gao Q, Guo Ding Z, Khuntirat B, Sattabongkot J, Wilkerson RC. Up dated distribution records of the Anopheles (Anoph eles) hyrcanus species-group (Diptera: Culicidae) in China. Zootaxa. 2007;1407:43-55. 10. Rueda LM, Gao Q. New records of Anopheles belenrae Rueda (Diptera: Culicidae) in North Ko rea. Proc Entomol Soc Wash. 2008;110:523-524. 11. Miyake M. Study on the anopheline mosquitoes in Kyushu. Hukuoka Acta Med. 1950;41:918-927. 12. Miyazaki I. On a new anopheline mosquito Anoph eles yatsushiroensis n. sp. found in Kyushu, with some remarks on two related species of the genus. Kyushu Mem Med Sci. 1951;2:195-206. MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE)

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July September 2014 17 13. Otsuru M, Ohmori Y. Malaria studies in Japan af ter World War II. Part II. The search for Anopheles sinensis sibling species group. Japan J Exp Med. 1960;30:33-65. 14. Tanaka K, Mizusawa K, Saugstad ES. A revision of the adult and larval mosquitoes of Japan (includ ing the Ryukyu Archipelago and the Ogasawara Islands) and Korea (Diptera: Culicidae). In: Con tributions of the American Entomological Institute Vol 16. Gainesville, Florida: American Entomolog ical Institute; 1979:1-987. 15. Imanishi N. Morphological and Phylogenetic Study of Anopheles belenrae First Recorded from Hokkaido, Japan [masters thesis]. Kanagawa, Ja pan: Meiji University; 2013. 16. Klein TA, Kim HC, Lee WJ, Rueda LM, et al Re emergence, persistence and surveillance of vivax malaria and its vectors in the Republic of Korea. In: Robinson WK, Bajoni D, eds, Proceedings of the Sixth International Conference on Urban Pests Budapest Hungary 2008. 325-331. Available at: http://www.icup.org.uk/reports/ICUP892.pdf. Ac cessed May 7, 2014. 17. Wilkerson RC, Li C, Rueda LM, Kim HC, Klein tion of Anopheles (Anopheles) lesteri from the Re public of South Korea and its genetic identity with An. (Ano.) anthropophagus from China (Diptera: Culicidae). Zootaxa. 2003;378:1-14. 18. Li C, Lee JS, Groebner JL, Kim HC, Klein TA, OGuinn ML, Wilkerson RC. A newly recognized species in the Anopheles Hyrcanus Group and mo Republic of South Korea (Diptera: Culicidae). Zoo taxa. 2005;939:1-8. 19. Knight K, Stone A. A Catalog of the Mosquitoes of the World (Diptera: Culicidae) Vol 6. College Park, Maryland: Entomological Society of Amer ica; 1977. 20. Harrison BA, Scanlon JE. Medical entomology studies II. The subgenus Anopheles in Thai land (Diptera: Culicidae). In: Contributions of the American Entomological Institute Vol 12, No. 1. Gainesville, Florida: American Entomological In stitute; 1979:1-307. 21. Rueda LM, Li C, Kim HC, Klein TA, Foley DH, Wilkerson RC. Anopheles belenrae a potential vector of Plasmodium vivax in the Republic of Ko rea. J Am Mosq Control Assoc. 2010;26(4):430-432. 22. Harrison GF, Foley DH, Rueda LM, et al. Plasmo dium pretable results and non-Plasmodium spp. sequenc Am J Trop Med Hyg. 2013;89(6):1117-1121. 23. Hwang UW, Yong TS, Ree HI. Molecular evi dence for synonymy of Anopheles yatsushiroen sis and An. pullus J Am Mosq Control Assoc. 2004;20(2):99-104. 24. Shin EH. Hong HK. A new synonym of Anopheles (Anopheles) pullus Yamada, 1937: A. (A.) yatsushi roensis Miyazaki, 1951. Kor J Entomol. 2001;31:1-5. AUTHORS Dr Rueda is a Research Entomologist, Principal Investi gator, and Acting Chief of the Walter Reed Biosystemat ics Unit, Entomology Branch, Walter Reed Army Insti tute of Research, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland. Mr Benedict Pagac is the Chief, Entomology Section at the US Army Public Health Command Region-North, Fort George G. Meade, Maryland. Mr Iwakami is an Entomologist at the US Army Public Zama, Japan. Ms Spring is a Molecular Biologist at the Entomology Section, US Army Public Health Command RegionNorth, Fort George G. Meade, Maryland. Dr Motoki is a Postdoctoral Entomologist at the Ento mology Department, Smithsonian Institution, Museum Support Center, Suitland, Maryland. Mr Pecor is a Museum Specialist at the Walter Reed Biosystematics Unit, Entomology Branch, Walter Reed Army Institute of Research, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland. Dr Higa, Dr Futami, and Ms Imanishi are Assistant Pro fessors and Graduate Student, respectively, at the De partment of Vector Ecology and Environment, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki City, Nagasaki, Japan. MAJ Long is currently on training leave from his po sition as Chief of the Walter Reed Biosystematics Unit, Entomology Branch, Walter Reed Army Institute of Re search, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland. COL Debboun is the Chief of the Department of Preven tive Health Services, Academy of Health Sciences, US Army Medical Department Center & School, Fort Sam Houston, Texas. He is also the Chairman of the Army Medical Department Journal Editorial Review Board.

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18 http://www.cs.amedd.army.mil/amedd_journal.aspx MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE) Summary of collection localities and larval habitats for Anopheles (Anophleles) in 4 prefectures of Kyushu Island, Japan (part 1 of 3). Prefecture Location Grid coordinates Collection date Stage Collector Habitat type b Collection No. Anopheles ( Anopheles ) Species Fukuoka Akagawa, Ogori City 33.34975N/130.51352E 19-20 Sep 2008 Adult a L. M. Rueda, Y. Oneda RC JP08-9 sinensis Fukuoka Takejima, Yasutakemache, Kurume 33.34975N/130.54597E 19-20 Sep 2008 Adult a L. M. Rueda, Y. Oneda RC KP08-10 sinensis Kumamoto Amitsu, Uto City 32.69973N/130.60432E 23 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano ID, RP JP08-17, 18 sinensis Kumamoto Gyokuto City, Tamana County 32.91638N/130.62565E 22 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano PO JP08-14 sinensis Kumamoto Hitoyoshi 32.22652N/130.77038E 12 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami ID, RH, RP JP13-19, 21 Hyrcanus Group c Kumamoto Kato shrine, Yatsushiro 32.47998N/130.57202E 15 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano DD JP08-2 lesteri Kumamoto Lake Ezu 32.77755N/130.73855E 24 Sep 2008 Adult L. M. Rueda, M. Iwakami, J. Santano LM JP08-19 sinensis Kumamoto Matsubase, Uki City 32.65355N/130.67050E 30 Aug 2006 Adult a M. Iwakami, R. Moore RP JP06-2-37A, 40A lesteri Kumamoto Matsubase, Uki City 32.65625N/130.66788E 17 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano RP JP08-7, 8 lesteri Kumamoto Matsubase, Uki City 32.65355N/130.67050E 30 Aug 2006 Adult a M. Iwakami, R. Moore RP JP06-2-1A, 2A, 3A, 4A, 6A, 25A; JP08-5, 6 sinensis Kumamoto Sumiyoshi, Uto City 32.70005N/130.60015E 22 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano ID JP08-17B sinensis Kumamoto Takasima, Yatsushiro 32.52158N/130.57750E 15 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano HD, WT JP08-1, 4 lesteri Kumamoto Tamana City, Tamana County 32.91638N/130.54523E 22 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano RP JP08-15, 16 sinensis Kumamoto Ueki City 32.88017N/130.68148E 22 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano ID, RP JP08-12, 13 lesteri Kumamoto Uto 32.69660N/130.66845E 29 Aug 2006 Adult a M. Iwakami, R. Moore RP JP06-1-50A, 51A lesteri Kumamoto Uto 32.69660N/130.66845E 29 Aug 2006 Adult a M. Iwakami, R. Moore RP JP06-1-1A, 2A, 3A, 4A, 5A, 7A, 16A sinensis Kumamoto Yatsushiro 32.50033N/130.61932E 11 Jul 2013 Larva, pupa, adult a L. M. Rueda, B. Pagac, M. Iwakami SP JP13-18 Hyrcanus Group c Kumamoto Yatsushiro 32.52158N/130.57750E 16 Sep 2008 Adult a L. M. Rueda, M. Iwakami, J. Santano RP JP08-3 sinensis Nagasaki Ariake-cho, Nagasaki 32.69414N/130.32505E 20 Jul 1988 Adult a RC JPM-5 sinensis Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Larva, pupa L. M. Rueda, B. Pagac, M. Iwakami ID JP13-31 Hyrcanus Group c Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-30 Hyrcanus Group c a Field collected larvae or pupae, reared to emerged adults. b DD, drainage ditch; HD, hill or road side ditch; ID, irrigation ditch; LM, lake margin; PO, pond; RC, resting at cowshed or cattle barn; RH, rock hole, pool; RP, rice paddy; SP, stream or river margin or pool; WT, water tank, trough or PVC tube waterer. c DNA isolation and sequencing still to be completed.

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July September 2014 19 Summary of collection localities and larval habitats for Anopheles (Anophleles) in 4 prefectures of Kyushu Island, Japan (part 2 of 3). Prefecture Location Grid coordinates Collection date Stage Collector b Habitat type c Collection No. Anopheles ( Anopheles ) Species Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Adult a L. M. Rueda, B. Pagac, M. Iwakami RP JP13-30 Hyrcanus Group d Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-32 Hyrcanus Group d Nagasaki Goto, Fukue Island 32.67867N/128.76802E 17 Jul 2013 Adult a L. M. Rueda, B. Pagac, M. Iwakami RP JP13-32 Hyrcanus Group d Nagasaki Isahaya 32.81308N/130.12767E 12 Jul 2013 Adult a NG1 PO JP13-23 Hyrcanus Group d Nagasaki Isahaya 32.81308N/130.12767E 12 Jul 2013 Larva NG1 PO JP13-23 Hyrcanus Group d Nagasaki Isahaya 32.81308N/130.12767E 12 Jul 2013 Larva NG1 RP JP13-25 Hyrcanus Group d Nagasaki Isahaya-shi, Kamiimuta, Moriyama-cho 32.80759N/130.10737E 27 May 2006 Adult T. Yoshio JPM-5 sinensis Nagasaki Mikawa-machi 32.78590N/129.88779E 27 May 1962 Adult NU JPM-5 sinensis Nagasaki Moriyama 32.83508N/130.11372E 9 Jul 2013 Adult a L. M. Rueda, B. Pagac, M. Iwakami RP JP13-7 Hyrcanus Group d Nagasaki Moriyama 32.83508N/130.11372E 9 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-8 Hyrcanus Group d Nagasaki Nagasaki 32.77217N/129.86950E 20 Jun 1989 Adult M. Mogi RP JPM-5 sinensis Nagasaki Nomozaki 32.58570N/129.75660E 15 Jul 2013 Larva NG2 AC JP13-26 Hyrcanus Group d Nagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-14 Hyrcanus Group d Nagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-15 Hyrcanus Group d Nagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami WC JP13-16 Hyrcanus Group d Nagasaki Obama-Unzen 32.71354N/130.20073E 10 Jul 2013 Adult a L. M. Rueda, B. Pagac, M. Iwakami WC JP13-16 Hyrcanus Group d Nagasaki Onako 32.88408N/129.69598E 16 Jul 2013 Larva NG2 RP JP13-29 Hyrcanus Group d Nagasaki Togitsu 32.82683N/129.84866E 7-9 Aug 1956; 22 Jul 1962 Adult NU JPM-5 sinensis Nagasaki Tsushima 34.17745N/129.29039E 27 May 1962 Adult NU JPM-5 sinensis Nagasaki Utzutzugawa 32.79328N/129.92803E 9 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-13 lindsayi japonicus Nagasaki Utzutzugawa 32.79328N/129.92803E 9 Jul 2013 Larva L. M. Rueda, B. Pagac, M. Iwakami RP JP13-13 Hyrcanus Group d Saga Fukutomi 33.17567N/130.17284E 13, 20, 28 Aug 2005; 11, 13, 24 Sep 2005; 10 Oct 2005; Adult M. Mogi LF JPM-22-1 sinensis a Field collected larvae or pupae, reared to emerged adults. b NG 1 indicates L. M. Rueda, B. Pagac, M. Iwakami, Y. Higa, K. Futami, N. Imanishi. NU indicates Nagasaki University, Entomology Collection. NG2 indicates L. M. Rueda, B. Pagac, M. Iwakami, Y. Higa, K. Futami. c AC, artificial containers (tires, plastic jugs, kettle, etc); CA, road ditch or small canal; ID, irrigation ditch; LF, lotus field; PO, pond; RP, rice paddy; WC, water well/cistern. d DNA isolation and sequencing still to be completed.

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx MOSQUITO BIOSURVEILLANCE ON KYUSHU ISLAND, JAPAN, WITH EMPHASIS ON ANOPHELES HYRCANUS GROUP AND RELATED SPECIES (DIPTERA: CULICIDAE) Summary of collection localities and larval habitats for Anopheles (Anophleles) in 4 prefectures of Kyushu Island, Japan (part 3 of 3). Prefecture Location Grid Coordinates Collection date Stage Collector Habitat type b Collection No. Anopheles ( Anopheles ) Species Saga Kase 33.23807N 130.25824E 17 Sep 2005 Adult M. Mogi ID JPM-21-1, -2, -3 sinensis Saga Kinyu 33.24204N 130.29149E 2, 5, 10 Jun 1986 Adult M. Mogi RP JPM-8, 9 lesteri Saga Morita 33.09454N 130.10894E 16 May 1995 Adult M. Mogi CA JPM-14 sinensis Saga Nabeshima 33.27991N 130.26614E 30 May 1985; 14 Jun 1985; 3, 5, 6, 7, 20 Jun 1986; 9 Jun 1990; 7 Jun 1995; 3 Jun 1996 Adult M. Mogi LF JPM-4, 5, 6, 7 lesteri Saga Shiroishi 33.17837N 130.14394E 7 May 2000 Adult M. Mogi RP JPM-19-1 lesteri Saga Shiroishi 33.17837N 130.14394E 3 Nov 1997; 7 May 2000 Adult M. Mogi NE JPM-14, 15, 19-2, 19-3, 19-5, 19-5 sinensis Saga Yamato-cho 33.14766N 130.14832E 10 Apr 2000 Adult T. Sunahara CA JPM-18 lesteri Saga Yamato-cho 33.14766N 130.14832E 5 Jun 1986; 24, 25, 26 Apr 2000; 10, 11, 12, 25 May 2000; 24, 25 Apr 2004 Adult T. Sunahara, M. Mogi CA JPM-8, 15, 16, 17, 18 sinensis Saga Tosu City 33.34463N 130.51352E 20 Sep 2008 Adult a L. M. Rueda, Y. Oneda GT JP08-11 lesteri a Field collected larvae or pupae, reared to emerged adults. b CA, road ditch or small canal; GT, ground pit or depression; ID, irrigation ditch; LF, lotus field; NE, caught by insect net; RP, rice paddy. Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines (NLMs) bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal to researchers during searches for relevant information using any of several bibliographic search tools, including the NLMs PubMed service.

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July September 2014 21 1 2-4 Anaplasma phagocytophilum Ehrlichia spp, Borrelia spp ( B burgdorferi B afzelii and B garinii Leishmania Plasmodium MA T E RI A LS A ND ME THODS Homogenization of Arthropods High-Throughput Vector-Borne Disease Environmental Surveillance By Polymerase Chain Reaction According To International Accreditation Requirements ABSTR A CT

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22 http://www.cs.amedd.army.mil/amedd_journal.aspx Automated Nucleic Acid Extraction DNA and RNA Absorbance Analysis Real-Time PCR Real-Time Reverse Transcription PCR Calculations t RE SULTS Plasmodium Leishmania Anaplasma phagocytophilum Ehrlichia Borrelia HIGH-THROUGHPUT VECTOR-BORNE DISEASE ENVIRONMENTAL SURVEILLANCE BY POLYMERASE CHAIN REACTION ACCORDING TO INTERNATIONAL ACCREDITATION REQUIREMENTS

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July September 2014 23 4 m m m m m p) COMM E NT tion point is often referred to as a crossing point (C p ) or a crossing threshold (C t ). Fluorescence is represented on The units are directly associated with the strength of sig S Cycle numbers performed should be optimized to each in will range from 30 to 50. Relative Fluorescence Units Cycle Number (increasing ) (d 2 F/dT) m product is correct based upon the nucleotide base con Relative Fluorescence Units (-dF/dT) Increasing Temperature (C)

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24 http://www.cs.amedd.army.mil/amedd_journal.aspx Method Accreditation Standardization Traceability Staff Turnover and Training Proficiency Testing HIGH-THROUGHPUT VECTOR-BORNE DISEASE ENVIRONMENTAL SURVEILLANCE BY POLYMERASE CHAIN REACTION ACCORDING TO INTERNATIONAL ACCREDITATION REQUIREMENTS Average melting temperature (T m ) values and standard devi ation (SD) for individual pathogens determined from a clean Target in Clean Matrix T m (C) one SD A. phagocytophilum 78.49 0.80 Crimean Congo hemorrhagic fever virus 80.90 0.69 Ehrlichia ssp 79.72 0.81 Borrelia ssp 79.34 0.12 Chikungunya virus 81.90 3.53 Dengue virus 81.62 2.96 Leishmania ssp 74.72 1.22 Plasmodium ssp 80.00 1.03 Sandfly fever Sicilian virus 77.96 0.54

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July September 2014 25 Flexibility Throughput Safety Department of the Army Pam phlet 385-69 Biosafety in Microbiological and Bio medical Laboratories and Quality Assurance/Quality Control Guidance for Laboratories Performing PCR Analyses on Environmental Samples

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26 http://www.cs.amedd.army.mil/amedd_journal.aspx CONCLUSION ACKNOWL E DGM E NTS RE F E R E NC E S US Army Med Dep J anaplas ma phagocytophilum and Borrelia burgdorferi J Clin Microbiol Vector-Borne Zoonotic Dis Appl Environ Microbiol Department of the Army Pamphlet 385-69: Safety Standards for Microbiological and Biomedical Laboratories Biosafety in Microbiological and Biomedical Lab oratories Quality Assurance/Quality Control Guidance for Laboratories Performing PCR Analyses on Envi ronmental Samples AUTHORS HIGH-THROUGHPUT VECTOR-BORNE DISEASE ENVIRONMENTAL SURVEILLANCE BY POLYMERASE CHAIN REACTION ACCORDING TO INTERNATIONAL ACCREDITATION REQUIREMENTS

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July September 2014 27 Rabies is an acute, progressive, viral encephalomyelitis with the highest case fatality rate of any conventional etiological agent. It is one of the oldest described in fectious diseases, having been recognized more than 4,000 years ago. Rabies has a substantial international presence in that it is distributed on all continents but Antarctica. It is the leading viral zoonosis with a sig health. Globally, the number of human rabies exposures per year is estimated to be in the tens of millions; the number of human rabies deaths per year was estimated to be over 55,000 in 2005. 1 The rabies virus is a negative strand RNA-virus belonging to the genus Lyssavirus, family Rhabdoviridae of the order Mononegavirales. 2,3 Different animal species are involved in the maintenance and transmission of rabies around the world. While the predominance of any one reservoir species varies by geographical region, the domestic dog remains the most numbers and with regard to transmission, accounting for more than 90% of rabies exposures worldwide and more than 99% of human rabies deaths. Although rabies con trol and elimination is possible in dogs, stray and freeroaming, infected dogs present barriers to success. 1,4,5 World Health Organization (WHO), which includes Afghanistan and Iraq, 6 rabies continues to be a public health problem, predominantly affecting vulnerable, impoverished populations living in remote, rural loca tions. In 2002, 5,000 human rabies deaths were recorded in the region, mostly from Afghanistan, the Islamic Re public of Iran, and Pakistan, whereas most other coun tries reported fewer than 10 cases per country. 7 Unlike in developed countries, vaccination coverage of domes tic animals in Afghanistan, Iraq, and similar countries is low. Absence of adequate vaccination within these countries makes them high risk for rabies in terrestrial animals and has resulted in a high prevalence of rabies within the dog population. 7,8 Unfortunately, current reported numbers of animals in fected with rabies in Iraq and Afghanistan are variable. Infrastructure is not in place to support testing for rabies in these regions, so reporting of cases is often based on clinical signs and is therefore limited and inconclusive. 9 These countries lack a much needed, effective surveil lance network to assess the magnitude of disease and to focus vaccination and control efforts. These countries also lack proper diagnostic facilities. Reliable national, systematic surveillance of rabies-related human deaths and animal rabies prevalence is urgently needed to gar ner support for effective prevention strategies. 4,10,11 body test (DFAT) is the most frequently used and is the gold-standard test approved by the Centers for Disease Control and Prevention (CDC), WHO, and the World Organisation for Animal Health. This test is performed Evaluation of a Rapid Immunodiagnostic Rabies Field Surveillance Test on Samples Collected from Military Operations in Africa, Europe, and the Middle East Kristen M. Voehl, DVM, MPH, DACVPM LTC Greg A. Saturday, MS, USA ABSTR A CT The Anigen Rapid Rabies Antigen Test Kit (Bionote, Inc, Hwaseong, Korea) was evaluated using 80 clinical samples collected by US military veterinary units. Samples for the study were obtained from brain specimens of domestic and wildlife animals that were submitted to the US Army Public Health Commands Veterinary Laboratory Europe test was able to detect rabies virus antigen in clinical samples of brain tissue. The rapid immunodiagnostic test had conditions and without a microscope or electricity, and yield results in 5 to 10 minutes. This rapid immunodiagnos tic test is a quick, inexpensive, and easy to use surveillance tool that can identify rabies positive animals and help focus targeted control measures with the goal of reducing the rabies burden.

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28 http://www.cs.amedd.army.mil/amedd_journal.aspx on brain tissue from animals suspected of being rabid and can only be performed postmortem. 12-15 The DFAT is one of the quickest and most reliable testing methods, providing an accurate diagnosis in 98% to 100% of ra bies suspect cases. 13,16,17 In remote locations, the use of DFAT is often not feasible because of transportation issues and lack of adequate cold chain. Laboratories are not able to comply with the strict requirements to perform DFAT accurately. The lack of infrastructure and logistical support hinders DFAT as a realistic expectation. Currently cases go un detected, and surveillance is not actively pursued. The lack of diagnostic and surveillance capability results in a low level of awareness of the actual incidences of ra bies in these regions, and the virus remains hidden and endemic with a potential to increase. 18 The US Army did evaluate the use of another test, the direct rapid immu an inexpensive test with excellent sensitivity and speci training, refrigeration, multiple chemicals, and proper microscopic training made this unrealistic as a suitable surveillance test in military environments. There are many challenges in the implementation of ef fective rabies diagnosis and surveillance programs in developing countries. Development and international acceptance of a validated test that can be used world wide are essential to overcome these challenges. Fi nancial and logistical barriers are additional obstacles that prevent use of such a test in developing countries with the greatest need. A rapid immunodiagnostic test (RIDT) for rabies virus has been developed, and this test shows potential in meeting these criteria. This lat including a monoclonal antibody directed against the lyssavirus nucleoprotein. 18 Although this method has only been used for qualitative analysis, it provides rapid detection of rabies antigen. Advantages over conven tional immunoassays include lower cost, inexpensive equipment, simplicity of procedure, rapid operation, and long-term stability over a range of environmental conditions. The test is suited for on-site testing by per sonnel with limited technical expertise. 18,19 Anigen Rapid Immunodiagnostic Test Kit for detection of rabies virus in clinical samples for application as a surveillance test among animal populations in areas with deployed military units. Clinical samples had previously been submitted to the US Army Public Health Command Region Europe Veterinary Laboratory Europe (VLE), in Landstuhl, Germany, for rabies testing with the DFAT. MA T E RI A LS A ND ME THODS Clinical Samples, Field Isolates, and Diagnosis A total of 79 clinical samples collected between 2004 and 2011 were examined for rabies using the Anigen RIDT. An additional clinical sample from 1996 was also tested. Total samples numbered 80. As shown in Table 1, all specimens were brain tissue collected from the following animals: canine (n=46), bovine (n=5), feline (n=18), macaque (n=3), porcine (n=1), mongoose (n=1), Iraq (n=26) or Afghanistan (n=45). Samples also origi nated from Turkey (n=1), Bosnia (n=1), Germany (n=3), Kuwait (n=3), and Qatar (n=1). Detailed information about the animals was not available. All samples were collected by US military personnel and submitted to 2010, all specimens were from banked samples stored at VLE and previously tested with DFAT and, in some cas es, with rabies murine neuroblastoma cell culture (MN). Thus, at that time, all results were previously known positives or negatives, and the investigators were not blinded to the results. Since that initial batch run of 39 tests, the RIDT was used concurrently on samples at the time of testing with DFA and MN. The sensitivity and the reference method. Rapid Immunodiagnostic Test Kit Test Principles The Anigen Rapid Rabies Antigen Test Kit (Bionote, Inc, Hwaseong, Korea) is an immunochromatographic assay designed for the qualitative detection of rabies virus an tigen in canine, bovine, and raccoon dog salivary secre gated detector antibodies to detect rabies virus antigen. 20 Application of the RIDT The rapid immunodiagnostic test was performed ac cording to the instructions supplied by the manufactur er. 20 after application of the sample as per the guidelines. In 2 tion of the sample to the test well. Examples of positive and negative results are shown in the Figure. RE SULTS Sensitivity and Specificity of the RIDT Kit Of the 80 samples used in the study, 45 were negative on DFAT, 32 were positive on DFAT, and 3 had an in determinate result on DFAT. When the RIDT was run on these samples, there were 49 negative results and 31 positive results. Although the intensity of the test lines EVALUATION OF A RAPID IMMUNODIAGNOSTIC RABIES FIELD SURVEILLANCE TEST ON SAMPLES COLLECTED FROM MILITARY OPERATIONS IN AFRICA, EUROPE, AND THE MIDDLE EAST

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July September 2014 29 was found to vary among the different samples, all tests were clearly readable. Seventy-eight samples reacted within the 10-minute cut-off time for inter preting the test, but 2 samples were negative at 10 minutes and had faint positive results at 30 minutes. The 3 tests that were indeterminate on DFAT were negative on the RIDT. Thirty-six of the 41 samples tested with both DFAT and RIDT in 2011 had also been tested with rabies murine neuroblastoma cell culture (MN). Of the 36 samples, 31 were negative on all tests, 3 were positive on all tests, and 2 were indeterminate on DFAT and MN but negative on RIDT. One of the samples that was indeter minate on DFAT and MN but negative on RIDT was from a bat from Af ghanistan. The other sample that was indeterminate on DFAT and MN but negative on RIDT was from a canine from Afghanistan. The third sample that was indeterminate on DFAT and negative on RIDT was from a canine from Kuwait. This sample was not Using DFAT as the reference method for the results of the samples tested, The 3 tests that were indeterminate on DFAT and MN were not used in the calculations. Results by Species and Geographic Region Results obtained from using the RIDT were evaluated by species (Table 2) and geographic region (Table 3). Given the concern regarding interactions between mili tary personnel and canines, the results for this species in presence, are further highlighted here. Canine Forty-six canine samples were tested. Exclud ing the samples with indeterminate results, sensitivity the study. Afghanistan Excluding the indeterminate results, the samples. Iraq Based on interpretation of the de layed test results as positive, the RIDT for Iraq samples. Using the 10-minute recommended cutoff time for RIDT interpretation, the sensitivity was 85%. COMM E NT In the present study, we describe a simple and rapid surveillance test for rabies virus infection based on the principle of immunochromatography. is widely used and accepted for the diagnosis of many human and animal diseases. Rabies surveillance is lacking for many areas where troops are deployed, and no rigorous epidemiological data ex ist largely because of the lack of op erational rabies diagnostic capabilities. application to gather surveillance data of rabies-suspect animals, especially cent antibody testing is impractical. 18 In this study, the RIDT was highly (100%) compared to the DFAT. The both 100%, compared to DFAT for the canine samples tested demonstrate the utility of the RIDT as a surveillance tool among canines, the rabies Table 1. Species and number of brain tissue samples tested with RIDT in this study from 1996 to 2011 Year Species Number of Samples Tested 1996 Bovine 1 2004 Canine 1 2005 Canine 2 2005 Porcine 1 2006 Canine 3 2007 Canine 3 2007 Mongoose 1 2008 Canine 5 2008 Bovine 4 2008 Jackal 1 2009 Canine 11 2009 Feline 2 2009 Macaque 2 2009 Equine 1 2010 Canine 1 2011 Canine 20 2011 Feline 16 2011 Rat 1 2011 Bat 3 2011 Monkey 1 NOTE: Bovine Bos primigenius Canine Canis familiaris Porcine Sus domesticus Mongoose Herpestidae Jackal Canis sp. Feline Felis catus Macaque Macaca sp. Equine Equus ferus Rat Rattus sp Bat Chiroptera sp. Examples of positive (top) and negative (bottom) results from the current study utilizing the rapid immunodiagnostic test.

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30 http://www.cs.amedd.army.mil/amedd_journal.aspx canines is limited for this study by the small sample sizes. Sensitivity separately for Afghanistan and Iraq, the 2 regions that had enough sam ples for meaningful interpretation. Afghanistan samples were 100% the RIDT. Iraq samples were 95% the RIDT. The data are presumably rabies in the region since samples were collected only by Army per sonnel in selected locations and not by local veterinarians throughout the regions. In addition, sensitivity the ability of the RIDT to detect re gional rabies virus variants. ty, simplicity, and brevity. 21 It is a straightforward test that is simple and quick to perform. There are no cold storage since the test kit is self contained and stable when stored at room temperatures or refriger ated. Kang el al 14 demonstrated that the test is capable of detecting low amounts of virus at an excel lent sensitivity level that is slightly less than that of a well-executed FAT. The study by Markotter et al 18 found excellent correlation of results when testing samples with both FAT and the RIDT. As with any new surveillance or diagnostic tool, strict quality con trol and test validation are essential before the test can be relied upon for meaningful results. Prelimi nary validation studies performed by Kang et al 14 showed the RIDT bies diagnostic method. In the present study, the sensi tivity of samples from Iraq must be considered in light tially negative on the RIDT after 10 minutes, but turned positive after 30 minutes. The delayed positive results could have been a result of the samples having a viral load close to the limit of detection, thus delaying the result. However, accurate interpretation is not pos sible outside of the manufacturers recommend time frame, 10 min utes for the RIDT. These 2 samples highlight the need for additional test validation. evaluations are needed, these re the RIDT as a surveillance tool in those regions without other imme diate capability. Capacity for effec tive rabies surveillance programs is crucial to determine those geo graphical areas of operations where soldiers may be at risk for encoun tering a rabid animal, especially among free-roaming dogs and dog den on military installations. Even though the RIDT was not evaluated on specimens other than dog, cattle, and raccoon dog in the initial study by Kang et al, 14 the re sults from the present study suggest that the RIDT may have applica tion as a surveillance tool for mul tiple species. Further research with greater case numbers in multiple species is necessary to determine if the RIDT is capable of detecting multiple rabies virus variants. Surveillance is an essential com ponent of infectious disease risk assessment of military members during deployments. 22,23 As a sur veillance tool, the RIDT can help guide the most appropriate and cost effective use of animal control pro cedures and resources where they are most needed and will be ben Continued on-site surveillance us ing the RIDT can also serve as a validation of vaccina tion control efforts. Military use of the RIDT has the po tential to lead to country-wide acceptance and approval of this test with implementation among local veterinary organizations. Because it does not require specialized equipment or training, RIDT kits would be an excellent EVALUATION OF A RAPID IMMUNODIAGNOSTIC RABIES FIELD SURVEILLANCE TEST ON SAMPLES COLLECTED FROM MILITARY OPERATIONS IN AFRICA, EUROPE, AND THE MIDDLE EAST Table 2. Comparison of the rapid immuno cent antibody test (DFAT, reference meth od) and murine neuroblastoma cell culture (MN) by species tested. Species Results Number of Samples RIDT DFAT MN Canine Positive 23 23 3 Negative 23 21 14 Indeterminate 2 1 Feline Positive Negative 18 18 15 Indeterminate Bovine Positive 4 5 Negative 1 Indeterminate Jackal Positive 1 1 Negative Indeterminate Macaque Positive Negative 3 3 1 Indeterminate Bat Positive Negative 3 2 Indeterminate 1 1 Rat Positive Negative 1 1 1 Indeterminate Mongoose Positive 1 1 Negative Indeterminate Porcine Positive 1 1 Negative Indeterminate Equine Positive 1 1 Negative Indeterminate Total Positive 31 32 3 Negative 49 45 31 Indeterminate 3 2 NOTE: Canine Canis familiaris Feline Felis catus Bovine Bos primigenius Jackal Canis sp. Macaque Macaca sp. Bat Chiroptera sp. Rat Rattus sp Mongoose Herpestidae Porcine Sus domesticus Equine Equus ferus

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July September 2014 31 supplies. This will further allow easy and accessible rabies surveil lance capabilities throughout the regions. According to the manufac turer (BioNote, November 6, 2013), a single test costs approximately less than the costs associated with establishing a laboratory equipped ACKNOWL E DG E M E NT We thank the staff and soldiers of the Veterinary Laboratory Europe who processed samples and par ticipated in evaluation of the RIDT. Special thanks to Leslie Fuhrmann for providing quality assurance in the rabies department and for her ex pertise in the testing process, and to LTC Jerry Cowart, MS, USA, Veter inary Pathology Division, Laborato ry Science, US Army Public Health Command Region-Europe, for his review of the manuscript. RE F E R E NC E S 1. Knobel DL, Cleaveland S, Cole man PG, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organ 2005;83(5):360-368. 2. De Benedictis P, De Battisti C, Dacheux L, et al. Lyssavirus detection and typing using py rosequencing. J Clin Microbiol 2011;49(5):1932-1938. 3. Switzerland: World Health Organization; 2012. Available at: http://www.who-rabies-bulletin.org/ 2012. 4. Horton DL, Ismail MZ, Siryan ES, et al. Rabies in Iraq: trends in human cases 2001-2010 and charac terisation of animal rabies strains from Baghdad. PLoS Negl Trop Dis 2013;7(2):e2075. 5. Lembo T, Hampson K, Kaare MT, et al. The fea sibility of canine rabies elimination in Africa: dispelling doubts with data. PLoS Negl Trop Dis 2010;4(2):e626. 6. Countries in the WHO Eastern Mediterranean Re Organization; 2012. Available at: http://www.who. int/about/regions/emro/en Accessed January 4, 2012. 7. Main challenges in the control of zoonotic diseases in the Eastern Mediterranean Region. Paper pre sented at: World Health Organiza tion regional committee report for session, agenda item 8; 2003:1-9. Available at: http://www.emro.who. int/docs/em_rc50_7_en.pdf. 8. Animal & Insect-Borne Dis Proving Ground, MD:US Army Public Health Command. Available at: http://phc.amedd.army.mil/top ics/discond/aid/Pages/FAQ.aspx. Accessed November 30, 2011. 9. Saturday G, King R, Fuhrmann L. Validation and operational appli cation of a rapid method for rabies antigen detection. US Army Med Dep J January-March 2009:42-45. 10. Coleman PG, Fvre EM, Cleaveland S. Estimating the pub lic health impact of rabies. Emerg Infect Dis 2004;10(1),140-142. 11. Wu X, Hu R, Zhang Y, Dong G, Rupprecht CE. Reemerging rabies and lack of systemic surveillance in Peoples Republic of China. Emerg Infect Dis 2009;15(8);1159-1164. 12. Centers for Disease Control and Prevention. Rabies Diagnosis: April 22, 2011. Available at: http:// www.cdc.gov/rabies/diagnosis/ac curacy.html Accessed January 11, 2012. 13. cent antibody test. In: Meslin FX, Kaplan MM, Ko prowski H, eds. Laboratory Techniques in Rabies Geneva, Switzerland: World Health Organization; 1996:88-95. 14. Kang B, Oh J, Lee C, et al. Evaluation of a rapid immunodiagnostic test kit for rabies virus. J Virol Methods 2007;145(1):30-36. 15. WHO Expert consultation on Rabies: First Report Geneva, Switzerland: World Health Organization; 2005. WHO Technical Report Series; 931. Avail able at: http://www.who.int/rabies/trs931_%20 06_05.pdf. Accessed June 5, 2014. 16. World Organisation for Animal Health. OIEs com Available at: http://www.oie.int/en/for-the-media/ rabies-worldwide/ Accessed June 5, 2014. Table 3. Comparison of the rapid immuno cent antibody test (DFAT, reference meth od) and murine neuroblastoma cell culture (MN) by geographic region. Region Results Number of Samples RIDT DFAT MN Afghani stan Positive 11 11 3 Negative 34 32 25 Indeterminate 2 2 Iraq Positive 19 20 Negative 7 6 2 Indeterminate Bosnia Positive 1 1 Negative Indeterminate Turkey Positive Negative 1 1 Indeterminate Germany Positive Negative 3 3 1 Indeterminate Kuwait Positive Negative 3 2 2 Indeterminate 1 Qatar Positive Negative 1 1 1 Indeterminate Total Positive 31 32 3 Negative 49 45 31 Indeterminate 3 2 Includes the 2 samples that did not show a positive result for 30 minutes One sample that was positive for DFAT and negative on RIDT was also positive on the DRIT.

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32 http://www.cs.amedd.army.mil/amedd_journal.aspx 17. Robles CG, Miranda NLJ. Comparative evaluation microscopic examination at the Research Institute for Tropical Medicine. Philipp J Microbiol Infect Dis 1992;21(2):69-72. 18. Markotter W, York D, Sabeta CT, et al. Evaluation of a rapid immunodiagnostic test kit for detec tion of African lyssaviruses from brain material. Onderstepoort J Vet Res 2009;76(2):257-262. 19. Wang H, Feng N, Yang S, et al. A rapid immuno chromatographic test strip for detecting rabies vi rus antibody. J Virol Methods 2010;170(1-2):80-85. 20. http://www.bionote. co.kr/File/Upload/2011/02/16/2011-02-16(10).pdf Accessed November 22, 2011. 21. Wharton M, Chorba TL, Vogt RL, Morse lic health surveillance MMWR Recomm Rep 1990:39(RR-13):1-43. 22. Murray CK, Horvath LL. An approach to preven tion of infectious diseases during military deploy ments. Clin Infect Dis 2007;44(3):424-430. 23. United States Air Force Guide to Operational Sur veillance of Medically Important Vectors and Pests: Operational Entomology Version 2.1. Washington, DC: US Dept of the Air Force; August 15, 2006. Available at: http://www.afpmb.org/sites/default/ pdf Accessed August 1, 2012. AUTHORS Dr Voehl is a staff veterinarian at the Army Veterinary Treatment Facility, Kaiserslautern, Germany. When the study described in this article was conducted, LTC Saturday was Chief, Veterinary Pathology Division, Army Veterinary Laboratory Europe, Landstuhl, Ger many. He is currently with the Comparative Pathology Branch, Research Support Division, US Army Medical Research Institute of Chemical Defense, Aberdeen Prov ing Ground, Maryland. EVALUATION OF A RAPID IMMUNODIAGNOSTIC RABIES FIELD SURVEILLANCE TEST ON SAMPLES COLLECTED FROM MILITARY OPERATIONS IN AFRICA, EUROPE, AND THE MIDDLE EAST

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July September 2014 33 Chronic obstructive pulmonary diseases are a group or chronic, chronic bronchitis, emphysema, asthma, bronchiectasis, extrinsic allergic alveolitis, and chronic 1 Emphysema and chronic structive pulmonary disease (COPD) (emphysema and constituted the third leading cause of death in the United Trends in Rates of Chronic Obstructive Respiratory Conditions Among US Military Personnel, 2001-2013 ABSTR A CT Background: Purpose: Methods: Results: ( P C onclusions:

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx 4 tal disorders, and musculoskeletal diseases, respiratory conditions can be debilitating and sufferers lives can implications for force readiness, allocation of military of the impacts of prolonged military engagement on in potential effect of deployment-associated environmen tal exposures on lung health is also of concern, but as Changes in the respiratory health of the US military population over time may result from variation in the sion standards, deployment-associated and other envi and evaluate longitudinal trends in rates of chronic respiratory conditions in the active duty US military What are the rates of these conditions in the mil itary population? Do the rates, and particularly the trends in these category, or rank? ME THODS Study Population Ascertainment of Respiratory Diagnoses monary diseases among US military personnel during diagnostic records for ambulatory medical encounters maintained in the Defense Medical Surveillance Sys the military health system and doctor visits in the pri calculated by dividing the total number of cases by the Definition of Respiratory Diagnoses from the person-time and rate calculations for subse Statistical Analysis We analyzed anonymized ambulatory encounter diag for year (year 2 TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS AMONG US MILITARY PERSONNEL, 2001-2013 Tricare is the Department of Defense health care program for members of the uniformed services, their families, and their sur vivors. Information available at http://www.tricare.mil.

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July September 2014 35 Differences in annual rates and evaluated by branch of military ser healthcare, other), and category of fered by branch of military service, main effects for year of diagnosis and indicator variables for each branch of group for analyses of service-specif reference group for military occupa served as the reference group for cat are presented using the primary case mated average rates for each respira tory diagnosis using the more strict RE SULTS Demographic Summary itary characteristics of the study population is presented We obtained diagnosis codes for the broad category ify as an incident case results in a further reduces the total number eight percent of the cases for this Rates of Bronchitis, Not Specified as Acute or Chronic (ICD-9 490) ambulatory medical encounters for among active duty US military per sonnel, yielding an average rate for ic increase in the estimated aver to all other branches of military service except for Ma Table 1 Demographic and military char acteristics, active component service members, 2001-2013 n % Gender Male 3,189,666 83.9 Female 611,010 16.1 Service Army 1,454,958 38.3 Navy 890,350 23.4 Air Force 784,278 20.6 Marine Corps 587,395 15.5 Coast Guard 83,695 2.2 Rank Junior Enlisted (E1-E3) 2,506,273 65.9 Senior Enlisted (E4-E6) 873,722 23.0 Junior Officer (O1-O3) 329,815 8.7 Senior Officer (O4-O6) 90,866 2.4 Military occupation Combat 818,644 21.5 Healthcare 277,607 7.3 Other 2,704,425 71.2 Age group (years) <20 475,754 12.5 20-24 1,801,244 47.4 25-29 793,778 20.9 30-34 451,184 11.9 35-39 191,551 5.0 40-44 64,255 1.7 45-49 17,327 0.5 50-54 3,971 0.1 168 0.0 Race, ethnicity White, nonhispanic 2,419,033 63.6 Black, nonhispanic 610,109 16.1 Other/unknown 771,534 20.3 *This is a dynamic population. To characterize time-varying characteristics (age and occupa tion), we identified all individuals in service for at least one day during the surveillance period (the population at risk), then identified the de mographic record closest to the midpoint of their period of service and used that record to identify age and military occupation. Data Source: Defense Medical Surveillance System.

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36 http://www.cs.amedd.army.mil/amedd_journal.aspx ( P P P cupations ( P listed personnel relative to senior enlisted personnel and P -shaped curve ( P quadratic year term P P son-years) returned to levels similar to those observed in for Marines than personnel in any other branch of mili P quadratic year term ( P quadratic year term P interactions military occupation ( P interactions rank ( P interactions Rates of COPD: Chronic Bronchitis, Emphysema, and Chronic Airways Obstruction, Not Elsewhere Classified ambulatory medical encounters for chronic bronchitis ( P P Marine Corps ( P P Guard ( P chronic bronchitis ( P P P nel had higher rates of chronic bronchi tis ( P P P chronic bronchitis ( P trend over time in emphysema rates that ( P trend P trend of these outcomes, the average an TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS AMONG US MILITARY PERSONNEL, 2001-2013 Table 2 Number and percentage of cases of selected chronic respiratory condi tions in the US military from 2001-2013 by ICD-9-coded condition. Respiratory Condition ICD-9 Code Primary Case Sensitive Case n % n % n % Bronchitis, not specified as acute or chronic 490 55,853 35.5 276,878 57.4 14,575 17.8 Chronic bronchitis 491 2,085 1.3 13,195 2.7 761 0.9 Emphysema 492 826 0.5 2,467 0.5 427 0.5 Asthma 493 94,858 60.2 177,234 36.7 64,026 78.2 Bronchiectasis 494 488 0.3 1,196 0.2 316 0.4 Extrinsic allergic alveolitis 495 104 0.1 680 0.1 55 0.1 Chronic airways obstruction, not elsewhere classified 496 3,302 2.1 11,020 2.3 1,683 2.1 The primary case definition required at least 2 ambulatory medical encounters recorded in DMSS with identical ICD-9 codes within 2 years (730 days). The more sensitive case definition required only a single ambulatory medical encounter with a given ICD-9 code. The more specific case definition required at least 3 ambulatory medical encounters recorded in the DMSS with identical ICD-9 codes within 2 years. Data Source: Defense Medical Surveillance System

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July September 2014 37 trend ( P trend P trend ( P trend P not observed for chronic bronchitis rates ( P inter actions nior enlisted personnel ( P interactions P interactions P interactions P inter actions personnel in combat occupations, relative to P in teractions over time ( P interactions sema over time ( P interactions Rates of Asthma asthma case resulted in a considerably higher P cupations ( P 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 0 80 40 30 20 10 50 60 70 ters within 2 years. counter. All Coast Guard Air Force Navy Army Marines 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Rate (per 10,000 person-years) 0 200 100 75 50 25 125 150 225 175 250 ters within 2 years. All Coast Guard Air Force Navy Army Marines 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 Rate (per 10,000 person-years) 0 5 25 30 20 10 15 Figure 1 chronic (ICD-9 490), within each US military service, 2001-2013

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38 http://www.cs.amedd.army.mil/amedd_journal.aspx senior enlisted ( P P P person-years ( P trend time trend in asthma rates varied by branch of military service ( P interactions military rank ( P interactions occupation ( P interactions ter ( P trend ( P trend Rates of Bronchiectasis and Extrinsic Allergic Alveolitis evidence that time trends in the rates of ei ther bronchiectasis or extrinsic allergic alveo litis varied over time ( P trend service ( P interactions pation ( P interactions ( P interactions COMM E NT evaluate longitudinal trends in rates of chron ic respiratory conditions in the active duty US chronic bronchitis and asthma over the study period, almost no change in the annual rates tent increases in the rates of respiratory illnesses in the group of chronic obstructive respiratory conditions TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS AMONG US MILITARY PERSONNEL, 2001-2013 tory conditions in the U.S. military for the 2001-2013 study period. Chronic Respiratory Condition Average Rate per 10,000 Person-years 95% Interval Lower Limit Upper Limit Bronchitis, not specified as acute or chronic (ICD-9 490 ) Primary case definition 27.73 21.43-35.88 Sensitive case definition 144.30 122.89-169.45 Specific case definition 7.00 5.1-9.5 Chronic bronchitis (ICD-9 491) Primary case definition 1.10 0.95-1.26 Sensitive case definition 6.45 4.82-8.63 Specific case definition 0.40 0.34-0.47 Emphysema (ICD-9 492) Primary case definition 0.43 0.37-0.50 Sensitive case definition 1.31 1.20-1.44 Specific case definition 0.21 0.17-0.27 Asthma (ICD-9 493) Primary case definition 49.05 40.49-59.42 Sensitive case definition 91.89 76.86-109.86 Specific case definition 32.78 26.18-41.03 Bronchiectasis (ICD-9 494) Primary case definition 0.24 0.18-0.32 Sensitive case definition 0.63 0.56-0.71 Specific case definition 0.15 0.10-0.21 Extrinsic allergic alveolitis (ICD-9 495) Primary case definition 0.05 0.05-0.06 Sensitive case definition 0.31 0.22-0.45 Specific case definition 0.03 0.02-0.04 Chronic airways obstruction, not elsewhere classified (ICD-9 496) Primary case definition 1.73 1.47-2.02 Sensitive case definition 5.81 5.10-6.62 Specific case definition 0.86 0.70-1.06 Averages were calculated by exponentiating the average of natural log-transformed an nual encounter rates. The primary case definition required at least 2 ambulatory medical encounters record ed in DMSS with identical ICD-9 codes within 2 years (730 days). The more sensitive case definition required only a single ambulatory medical encounter with a given ICD-9 code. The more specific case definition required at least 3 ambulatory medical encoun ters recorded in the DMSS with identical ICD-9 codes within 2 years. Data Source: Defense Medical Surveillance System.

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July September 2014 39 dence of persistence of the diagnosis in the medical re dramatic drop in the estimated rate of this diag nosis, more so than for any other of the conditions served among all military branches and across all slope of the trends in the conditions over time in the rate of medical encounters for respiratory ence group of personnel stationed in the United medical encounters for COPD and allied condi Szema et al reported an elevated risk of asthma 14 Szema et al also this later study, both groups had similar forced 1 itary personnel and Veterans participating in the ters within 2 years. All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 0 1 5 6 4 2 3 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 counter. All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 0 5 25 30 20 10 15 ters within 2 years. All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 0.0 0.5 2.5 2.0 1.0 1.5 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 Figure 2 Annual rates of chronic bronchitis (ICD9 491 ), by each US military service, 2001-2013

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40 http://www.cs.amedd.army.mil/amedd_journal.aspx Using outpatient medical encounter diagnosis data to estimate rates of chronic obstructive lung conditions al true incidence of a condition and clinical diagnosis for that condition that is not accounted for in this investiga evidence of persistence of the diagnosis and a more spe sponding to chronic obstructive respiratory conditions chitis, chronic bronchitis, and asthma temporal trend observed using our pri from ambulatory care encounters that are assigned an conditions likely remain undiagnosed and therefore not Potential explanations for the observed relationships founding by time-varying predictors of obstructive pul monary condition diagnoses, such as an external factor ble co-relationships so that trends independent of these TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS AMONG US MILITARY PERSONNEL, 2001-2013 Table 4. Trends in rates of encounters with chronic obstructive pulmonary diseases and allied conditions (ICD-9 490-496) in the US military, 2001-2013, by diagnosis.* Chronic Obstructive Pulmonary Disease or Allied Condition ICD-9 Code Percentage Increase in Trend dence Interval P value Lower Limit Upper Limit Bronchitis, not specified as acute or chronic 490 -2.54% -3.56 -1.51 0.0003 Chronic bronchitis 491 -3.61% -6.60 -0.52 0.0264 Emphysema 492 3.47% -0.46 7.55 0.0785 Asthma 493 -5.91% -9.23 -2.47 0.0033 Bronchiectasis 494 4.69% -2.89 12.85 0.2066 Extrinsic allergic alveolitis 495 2.35% -2.40 7.33 0.3057 Chronic airways obstruction, not elsewhere classified 496 0.12% -4.24 4.67 0.9547 Rates were estimated using a case definition that required evidence of persistence of the diagnosis in the medical record, i.e., at least 2 encounters with the same diagnosis code within 2 years. The percent increase in the linear slope is derived from the slope estimate from a regression model of year as a continuous independent predictor of natural log-transformed rates. A statistically significant curvinear trend was observed for the bronchitis, not specified as acute or chronic outcome. As such, we present only the percent change in the quadratic, de rived from the quadratic term from a regression model of year 2 as a continuous independent predictor of natural log-transformed rates in a model that also contains the main effect of year as a continuous independent predictor. Data Source: Defense Medical Surveillance System.

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July September 2014 41 focus on assessing rates of these conditions among RE F E R E NC E S Natl Health Stat Report Chronic obstructive pulmonary disease among MMWR Morb Mortal Wkly Rep Natl Vital Stat Rep MSMR J Trauma Stress J Trauma Longitudinal assessment of mental health prob lems among active and reserve component JAMA Arch Intern Med JAMA J Head Trauma Rehabil Am J Public Health Inhal Toxicology Figure 3 Annual rates of emphysema (ICD9 492 ), by each US military service, 2001-2013 ters within 2 years. All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 0.0 0.2 1.0 0.8 0.4 0.6 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 counter. All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 0.0 0.5 2.5 3.0 2.0 1.0 1.5 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 ters within 2 years. Rate (per 10,000 person-years) All Coast Guard Air Force Navy Army Marines 0.8 0.0 0.2 0.4 0.6 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007

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42 http://www.cs.amedd.army.mil/amedd_journal.aspx spective cohort study of military deployment and post-deployment medical encounters for respira Mil Med Allergy Asthma Proc J Occup Environl Med J Occup Environl Med stan affect respiratory health of US military per J Occup Environl Med of ambient particulate matter and cardiovascular and respiratory medical encounters among US J Occup Environl Med and conditions among military personnel deployed Am J Epidemiol lems, neurological conditions and heart disease Air Force Times Mil Med AUTHORS Dr Clark is a Senior Managing Epidemiologist in the Ms Sharkey is an Epidemiologist, Environmental Medi TRENDS IN RATES OF CHRONIC OBSTRUCTIVE CONDITIONS AMONG US MILITARY PERSONNEL, 2001-2013 Figure 4 Annual rates of asthma (ICD9 493 ) within each US mili tary service, 2001-2013 ters within 2 years. All Coast Guard Air Force Navy Army Marines Rate (per 10,000 person-years) 0 80 60 40 20 100 120 140 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 counter. Rate (per 10,000 person-years) All Coast Guard Air Force Navy Army Marines 0 200 100 75 50 25 125 150 225 175 250 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 ters within 2 years. Rate (per 10,000 person-years) All Coast Guard Air Force Navy Army Marines 0 10 50 80 60 40 20 30 90 70 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007

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July September 2014 43 Figure 5 Annual rates of chronic airways obstruction, not else 9 491 ), within each US military service, 2001-2013 ters within 2 years. Rate (per 10,000 person-years) All Coast Guard Air Force Navy Army Marines 0.0 0.5 3.5 2.5 4.0 3.0 2.0 1.0 1.5 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 counter. Rate (per 10,000 person-years) All Coast Guard Air Force Navy Army Marines 0 2 10 12 8 4 6 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007 ters within 2 years. Rate (per 10,000 person-years) All Coast Guard Air Force Navy Army Marines 0.00 2.00 1.00 0.75 0.50 0.25 1.25 1.50 1.75 2001 2002 2003 2004 2005 2006 2008 2009 2010 2011 2012 2013 2007

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx BA CKGROUND Concerns related to potential service-related expo larly, exposures occurring in theater while supporting 2-5 6,7 8 Current and future research ef forts will continue to investigate potential associations Long-Term Health Conse quences of Exposure to Burn Pits in Iraq and Afghani stan Congress collect data concerning potential exposures related to Department of Defense Participation in the Department of Veterans Affairs Airborne Hazards and Open Burn Pit Registry: Process, Guidance to Providers, and Communication

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July September 2014 45 Bahrain potheses for future efforts regarding the health status of VE T E R A NS purposes, veteran registry participants will have the op tionnaire responses electronically through the speciallyposes for veterans, and participation does not affect ac ACTIV E DUTY, RE S E RV E, A ND NA TION A L GU A RD PE RSONN E L cal and occupational health history, and the healthcare

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx RE GISTR A TION PROC E SS A ND SPE CIFICS for instructions if they are currently experiencing any on active duty and those who are not presently on ac For the location and scheduling of the voluntary For the location and scheduling of the voluntary WH A T MILIT A RY HEA LTHC A R E PROVID E RS SHOULD KNOW DEPARTMENT OF DEFENSE PARTICIPATION IN THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE HAZARDS AND OPEN BURN PIT REGISTRY: PROCESS, GUIDANCE TO PROVIDERS, AND COMMUNICATION

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July September 2014 47 tests, and there is no reporting of any results or clinical surance, clinical evaluations, and, when indicated, diag prehensive approach, including diagnostic testing and and training for physicians, physician-assistants, and its purpose, coding and recording guidance, and provide RISK COMMUNIC A TION essential that the provider instill in the patient a sense of

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48 http://www.cs.amedd.army.mil/amedd_journal.aspx Be sensitive that your own perceptions of service perceived and how to identify and develop appropriate ENVIRONM E NT A L ME DICIN E CLINIC A L CONSULT SE RVIC E for an exposure history and evaluation, so we encour DEPARTMENT OF DEFENSE PARTICIPATION IN THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE HAZARDS AND OPEN BURN PIT REGISTRY: PROCESS, GUIDANCE TO PROVIDERS, AND COMMUNICATION

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July September 2014 49 to tion to address individual concerns associated with en RE F E R E NC E S Am J Epidemiol J Air Waste Manag Assoc Inhal Toxicol Green Warriors: Army Environmental Considerations for Contingency Inhal Toxi col Army De ployments to OIF and OEF Marine Corps Times Department of Defense Instruction 4715.19: Use of Open-Air Burn Pits in Contingency Opera tions Screen ing Health Risk Assessment, Burn Pit Exposures, Balad Air Base, Iraq and Addendum Report

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50 http://www.cs.amedd.army.mil/amedd_journal.aspx N Engl J Med J Occup Environ Med Long-Term Health Conse quences of Exposure to Burn Pits in Iraq and Af ghanistan Science Department of Defense Instruction 6490.03: De ployment Health AUTHORS DEPARTMENT OF DEFENSE PARTICIPATION IN THE DEPARTMENT OF VETERANS AFFAIRS AIRBORNE HAZARDS AND OPEN BURN PIT REGISTRY: PROCESS, GUIDANCE TO PROVIDERS, AND COMMUNICATION

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July September 2014 51 Q fever is considered a worldwide zoonosis due to the intracellular rickettsia, Coxiella burnetti In the United States, data has shown a 3.1% seroprevalence. 1 However, prevalence rates vary widely among countries based on their ability to conduct proper surveillance. For example, rates are noted to be 18.3% in Morocco, 32.3% in Tur key, and 10% to 37% in northeast Africa. 2-4 Cautiously, these estimates may underestimate the true incidence of disease due to its polymorphic clinical presentation. 5 Typically, Q fever is considered an occupational hazard affecting persons in greatest contact with farm or labo ratory animals. The reservoir includes a variety of wild and domestic mammals, birds, and arthropods. 5 Urine, feces, milk, and birth products of infected animals are the main sources for transmission. Human infections primarily originate from either inhalation of contami nated aerosols or ingestion of raw milk products. The route of inhalation may occur directly from parturient 5 Additionally, it is highly resistant to harsh environments up to several weeks, and prevailing wind patterns have been known to transport this organism great distances from its source. 5 As a result, Q fever may occur in pa tients without history of animal contact. Furthermore, the long incubation period (14-21 days) of this disease contributes to its elusive presentation in both acute and chronic progression. 6 In acute cases, the most common clinical presentation is usually a self-limited febrile illness of unknown origin; however, there are degrees of its severity. Complications include but are not limited to granulomatous hepatitis, atypical pneumonia, and meningoencephalitis. 7 Al though not reported in the United States, progressive chronic fatigue has also been described in England and Australia; however, this syndrome is not considered di agnostic of an ongoing infection. 8-10 Rarely does chronic Q fever develop (1% of acute cases). It may occur, however, more often (39%) in patients with preexisting cardiac valvulopathy. 11 by a clinical evolution more than 6 months duration with the presence of phase 1 immunoglobulin (Ig) G C. burnetti antibodies. 5 The most common clinical mani festation of chronic infection is endocarditis involving the aortic and mitral valves. 5 Interestingly, the major ity of patients who develop chronic Q fever are older men (aged over 40 years) even though both genders may have similar exposures. 7 Risk factors include immu nosuppressed or immunocompromised persons, preg nancy, and vascular abnormalities. Nonetheless, preex remain the most predominant risk factor. 5,11,12 Without treatment, phase 1 IgG titers remain persistently high along with further clinical deterioration. 11,13 Diagnosis is primarily made by serologic testing. The 5,14 In the acute phase, phase 2 IgG and IgM antibodies are usu ally elevated around 1-2 weeks after the onset of symp toms, and around 90% of all cases seroconvert by the third week. 15 A phase 2 IgG antibody titer of 1:200 or more and a phase 2 IgM antibody titer of 1:50 or more are highly suggestive of an acute infection. 15 In contrast, the phase 1 IgG antibodies are predominant during chronic infections. In this stage, titers of 1:800 or more 15 Antibodies generally peak around 1-2 months after the onset of symptoms. 15 Gradually, the titers usually decrease in the following year; but IgG antibodies may persist while IgM antibod ies disappear. 15 When high levels of phase 1 antibodies remain positive, chronic Q fever is highly suggestive. 15 CA S E On March 31, 2011, a 39-year-old white female com plained of generalized myalgias, nausea, headache, night sweats, subjective fevers, and chills for the past day fol lowed by fatigue. Vitals were remarkable for slightly el evated heart rate (107) and temperature (101.9F). Her occupation was described as an Army Reserve nurse deployed to Mosul, Iraq, in a combat support hospital. history. She denied any sick contacts to either humans or animals. She also denied any contact to unusual food or Coinfection of Mycoplasma Pneumonia w ith Chronic Q Fever in a Nurse Deployed to Operation Iraqi Freedom: A Case Study LTC Paul O. Kwon, MC, USA Jason R. Pickett, MD

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx monospot test, and chest x-ray were all within normal the patient was prescribed a 5-day course of oseltamivir. Two days later, her symptoms progressed to nausea, skin. Although her blood cultures were negative, she was noted to have elevated liver enzymes: alanine ami notransferase (ALT 443), aspartate aminotransferase (AST 288) and alkaline phosphatase (AP 364). Yet, her right upper quadrant ultrasound was interpreted as nor with outpatient management. On April 12, 2011, the patient had reoccurring myal gias; however, she now developed rhinitis, headache, anorexia and night sweats. She was afebrile on the visit but demonstrated sinus tachycardia (heart rate 125) that ed a history of persistent fevers as high as 102F. Her physical exam was unremarkable. Although her urinal decreased hemoglobin (Hgb 11) levels, hyperglycemia (glucose 200), elevated erythrocyte sedimentation rate (ESR 49) and c-reactive protein (CRP 24), but a resolv ing transaminitis (ALT 90, AST 36, AP 184). During the second week of illness, the patient devel oped worsening erythematous, nonpruritic, but tender to palpation nodules on her bilateral legs (Figure 1). Ini tially, the primary diagnosis was presumed insect bites joint pains with nonresolving bilateral leg nodules and a progressive rash to both arms. The nodules now ap hands (Figure 2). A diagnosis of erythema nodosum was made. Additionally, she complained of wakening night were unremarkable as additional labs continued to re veal anemia (Hgb 9.6 with schistocytes) along with per and CRP 19.2). Other pertinent labs such as human im plasma reagin, leishmaniasis cultures, liver function tests, and thyroid panel were all concluded as negative. Her pelvic exam was normal, and antigens for gonor rhea and chlamydia were also negative. As a result, she was diagnosed with fever of unknown or igin and evacuated to Landstuhl Regional Medical Cen ter for further evaluation. Additional consultations re vealed a negative tuberculin skin test, antistreptolysin O, hepatitis panel, nuclear antibody panel, ferritin, rheuma toid factor, histoplasma and coccidiodies antibody titers. The TORCH panel* revealed positive IgG antibodies for cytomegalovirus, herpes simplex virus, and rubella with tory markers were on a declining trend (CRP 3.16, ESR 65). Notably, her mycoplasma antibody was positive and she was treated for mycoplasma pneumoniae On day 41, C. burnetti results, shown in the Table, re turned with a concern for Q fever. As a result, further cardiac testing was completed. An electrocardiogram re vealed a sinus arrhythmia while an echocardiogram di tation, as well as mild to moderate tricuspid regurgitation. COINFECTION OF MYCOPLASMA PNEUMONIA W ITH CHRONIC Q FEVER IN A NURSE DEPLOYED TO OPERATION IRAQI FREEDOM: A CASE STUDY A group of tests for toxoplasmosis, rubella, cytomegalovirus, her pes simplex, and HIV, but it can also include other infections. Figure 1. Worsening erythematous, nonpruritic, but tender to palpation nodules on the patients bilateral legs that de veloped during the second week of illness. Figure 2. Rash nodules on palms and legs.

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July September 2014 53 Detailed questioning failed to reveal any occupational or casual exposure to common Q fever vectors. The patient did not have any contact with livestock or likely animals. She had been quartered in an enclosed containerized side the combat support hospital housing area. Her CHU was located adjacent to a MEDEVAC helicopter landing zone where rotor downwash may have aerosolized soil particles that led to infection, although no other case re ed with doxycycline for a 3-week course and returned to the combat theater to complete her tour. Initially, her phase 2 IgM titers were elevated consistent with an acute infection on day 41. Increasing phase 2 IgG titers followed on day 218 even after treatment. Later, her constitutional symptoms of fever, rash, and night sweats eventually resolved. However, follow-up serologies re vealed persistent phase 1 IgG titers, consistent with a chronic infection. Two years after diagnosis, the patient complained only of persistent arthralgias varying from 2 to 5 out of 10 on a visual analog pain scale, a common complication of chronic disease. Follow-up titers indicated decreasing IgM titers consistent with convalescence, shown in the returned to normal levels. Repeat echocardiogram on January 24, 2013, showed mild thickening of the anterior COMM E NT Since Operation Iraqi Freedom began, there have been reports of over 100 cases of Q fever among deployed US military personnel ascertained through a Department of Defense medical database. 6,15-21 The most frequent pre sentation includes fever, pneumonia, or hepatitis. 8,22 De disease, Q fever is also known to possess a wide spec trum of manifestations including 7 distinct presentations described by Raoult: fever, pneumonia, hepatitis, men ingitis, meningoencephalitis, pericarditis, and myocardi tis. 8 Although cases of acute cholecystitis have been as sociated with this disease in some medical literature, 23-26 it is not well described as part of the Q fever diagnosis. Consequently, this broad variation in clinical presenta tion can delay diagnosis and further treatment. Our patient denied having typical risk factors including exposure to livestock or consumption of local meat or dairy products. However, it is known that direct expo sure to the source is not necessary for an infection to occur. 8,21,22 Further, coinfection with mycoplasma pneu moniae is not well described in the literature. However, atypical pneumonia have been discussed in limited re gions of the world 27 and more recently with investiga tions among HIV-infected patients. 28 Additionally, chronic Q fever is infrequently reported among females. Her valvulopathy discovered on echo cardiogram was considered mild to moderate without serious untoward symptoms or signs of endocarditis. There were no indications of a preexisting cardiac con fection of C. burnetti prompt treatment was initiated with direct follow-up. Subsequent laboratory studies cated clinical course. biologic agent and is a potential threat to deployed Sol diers. 29 In this case, direct contact with infected ani mals is not required for military personnel to be considered exposed. Transmission factors within military populations include sleeping in barns, tick bites, and living near helicopter landing zones where environmental aerosols are generated. 16 In conclusion, this case report is an important reminder to medical providers of the existence of a myriad of unique infectious sources among deployed Soldiers or those returning from abroad. A heightened awareness of this insidi ous disease will ensure prompt diagnosis and treatment ultimately preventing future complications. Lastly, the occupational and environmental history is a key determinant of success for any clinical practice. RE F E R E NC E S 1. Anderson AD, Kruszon-Moran D, Loftis AD, et al. Seroprevalence of Q fever in the United States, 2003-2004. Am J Trop Med Hyg 2009;81(4):691-694. Results of serologic testing for presence of Coxiella burnetti Date Phase 1 IgG Phase 2 IgG Phase 1 IgM Phase 2 IgM ESR CRP 04/27/11 <1:16 <1:16 1:1024 1:2048 65 3.16 05/23/11 1:256 1:4096 1:4096 1:2048 11/03/11 1:1024 1:16384 1:256 1:16 08/22/12 a Negative Negative 10/17/12 a 1:4096 1:8192 Negative b Negative 16 0.63 04/11/13 a 1:128 1:128 Not Performed Not Performed 11 0.40 a All subsequent lab results from 08/22/2012 to 04/11/2103 were processed by ARUP Laboratories (University of Utah, Salt Lake City). b Although the test was deemed negative by the laboratorys screening lab, titers were processed by the Director of Laboratory Operations and read as 1:16.

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx 2. Coxiella burnetii antibody prevalences among human popu lations in north-east Africa determined by enzyme immunoassay. J Trop Med Hyg 1995;98(3):173-178. 3. roepidemiology of rickettsial infections in Moroc co. Eur J Epidemiol 1995;11(6):655-660. 4. Kilic S, Yilmaz GR, Komiya T, Kurtoglu Y, Kara koc EA. Prevalence of Coxiella burnetii antibodies in blood donors in Ankara, Central Anatolia, Tur key. New Microbiol 2008;31(4):527-534. 5. Maurin M, Raoult D. Q fever. Clin Microbiol Rev 1999;12(4):518-553. 6. Gleeson TD, Decker CF, Johnson MD, Hartzell JD, Mascola JR. Q fever in US military returning from Iraq. Am J Med 2007;120(9):e11-e12. 7. Raoult D, Tissot-Dupont H, Foucault C, et al. Q fever 1985-1998. Clinical and epidemiologic fea tures of 1,383 infections. Medicine 2000;79(2):109-123. 8. Raoult D, Marrie T, Mege J. Natural history and pathophysiology of Q fever. Lancet Infect Dis 2005;5(4):219-226. 9. Ayres JG, Flint N, Smith EG, et al. Post-infec tion fatigue syndrome following Q fever. QJM 1998;91(2):105-123. 10. Ayres JG, Wildman M, Groves J, Ment J, Smith from the 1989 Q fever outbreak: no evidence of excess cardiac disease in those with fatigue. QJM 2002;95(8):539-546. 11. Fenollar F, Fournier PE, Carrieri MP, Habib G, Messana T, Raoult D. Risks factors and pre vention of Q fever endocarditis. Clin Infect Dis 2001;33(3):312-316. 12. D. Endocarditis after acute Q fever in patients with previously undiagnosed valvulopathies. Clin Infect Dis 2006;42(6):818-821. 13. Landais C, Fenollar F, Thuny F, Raoult D. From acute Q fever to endocarditis: serological follow-up strategy. Clin Infect Dis 2007;44(10):1337-1340. 14. Fournier PE, Marrie TJ, Raoult D. Diagnosis of Q fever. J Clin Microbiol 1998;36(7):1823-1834. 15. Leung-Shea C, Danaher PJ. Q fever in members of the United States armed forces returning from Iraq. Clin Infect Dis 2006;43(8):e77-e82. 16. Hartzell JD, Peng SW, Wood-Morris RN, et al. Atypical Q fever in US Soldiers. Emerg Infect Dis 2007;13(8):1247-1249. 17. Hartzell JD, Wood-Morris RN, Martinez LJ, Trotta RF. Q fever: epidemiology, diagnosis, and treat ment. Mayo Clin Proc 2008;83(5):574-579. 18. Faix DJ, Harrison DJ, Riddle MS, et al. Outbreak of Q fever among US military in western Iraq, JuneJuly 2005. Clin Infect Dis 2008;46(7):e65-e68. 19. Mil Med 2008;173(10):949-953. 20. Aronson NE, Sanders JW, Moran KA. In harms way: infections in deployed American military forces. Clin Infect Dis 2006;43(8):1045-1051. 21. Emerg Infect Dis 2005;11(8):1320-1322. 22. Lancet 2006;367(9511):679-688. 23. Rolain JM, Lepidi H, Harle JR, et al. Acute acalcu lous cholecystitis associated with Q fever: report of seven cases and review of the literature. Eur J Clin Microbiol Infect Dis 2003;22(4):222-227. 24. Reina-Serrano S, Jimenez-Saenz M, HerreriasGutierrez JM, Venero-Gomez J. Q fever-related cholecystitis: a missed entity?. Lancet Infect Dis 2005;5(12):734-735. 25. Modol JM, Llamazares JF, Mate JL, Troya J, Sa bria M. Acute abdominal pain and Q fever. Eur J Clin Microbiol Infect Dis 1999;18(2):158-160. 26. titis due to Coxiella burneti infection. Med J Aust 1986;144(3):151-152,154. 27. Marrie TJ, Haldane EV, Noble MA, Faulkner RS, Martin RS, Lee SH. Causes of atypical pneumo nia: results of a 1-year prospective study. CMAJ 1981;125(10):1118-1123. 28. Marrie TJ, Peeling RW, Fine MJ, Singer DE, Col ey CM, Kapoor WN. Ambulatory patients with community-acquired pneumonia: the frequency of atypical agents and clinical course. Am J Med 1996;101(5):508-515. 29. Daya M, Nakamura Y. Pulmonary disease from biological agents: anthrax, plague, Q fever, and tu laremia. Crit Care Clin 2005;21(4):747-763,vii. AUTHORS When this article was written, LTC Kwon was with the Department of Preventive Medicine, Madigan Army Medical Center, Tacoma, Washington. He is currently Chief of Preventive Medicine, US Army Medical Activi ty-Alaska, Fort Wainwright, Alaska. Dr Pickett is an Assistant Professor, Department of Emergency Medicine, Wright State University, Dayton, Ohio. He is also a Major in the West Virginia Army Na tional Guard where he serves as a battalion surgeon. COINFECTION OF MYCOPLASMA PNEUMONIA W ITH CHRONIC Q FEVER IN A NURSE DEPLOYED TO OPERATION IRAQI FREEDOM: A CASE STUDY

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July September 2014 55 HISTORY The acronym TCAPS, for Tactical Communication and Protection Systems, was introduced in the Army Hear ing Program Special Text 4-02.501, released in 2008, 1 and is quickly becoming a known and understood ac ronym in the vernacular of many American Soldiers Army line units. Broadly categorized as in-the-ear, overthe-ear, wired, or wireless, TCAPS is the generic term tion systems available for purchase. A number of manufacturers have employed modern hearing aid technology to create these systems for the military population using a variety of modern digital signal processing algorithms, including digital com pression and/or active noise reduction. In 1993, the Bose pany to supply an active noise reduction (ANR) system to the US Armys armored vehicle personnel with the combat vehicle crewman headset. 2 The more current TriPort Tactical Headset Series 2 ANR headset was used in many wheeled armored vehicles throughout Op eration Iraqi Freedom and continues to be used today in noise hazardous military vehicles such as the M-1114 High-Mobility, Multipurpose Wheeled Vehicle and the Stryker. In 2007, the US Marine Corps contracted with Marines with in-the-ear, wired TCAPS under the trade name of Integrated Intra Squad Radio Hearing Protec tion Headsets. 3 In 2012, the US Army Rapid Equipping Force acquired a source of supply code for the Peltor over-the-ear ComTac III headsets (3M Personal Safety Division, St Paul, MN) TCAPS for regular Army pur chase through the Defense Logistics Agency. Previously, the source of supply code had been maintained and used only by Special Operations Forces. 4 The TEA INVISIO X50 (TEA Inc, Brewster, NY) is one of the most current TCAPS receiving attention from the US Army Hearing Program. In October 2013, the US Armys Program Ex to TEA Inc for INVISIO X50 systems to address the TCAPS requirement. 5 gade combat teams during 2014 at Ft Campbell, Ft Drum, and Ft Bragg. 6 Even amidst these large scale contracts and research endeavors, we still see small groups of Soldiers who spend precious, limited unit funds or even their personal funds on one or more TCAPS devices and accessories. DA T A COLL E CTION This quality assurance data report concerns a US Army Alaska light infantry brigade (airborne) which rede ployed to their home duty station, the Fort Richardson side of Joint Base Elmendorf-Richardson, after a year long combat tour in Afghanistan. The infantrymans job description includes 3 tasks: shoot, move, and com municate. Good hearing is a force multiplier. A sudden temporary or permanent hearing loss from acoustic trauma in combat has the potential to render the indi vidual Soldier, or even the entire unit, ineffective, which could result in mission failure. Experience has shown that Soldiers completely understand the importance of both having robust, clear, communication abilities on for that capabilityhearing. All Soldiers who deploy or redeploy from combat are re quired to undergo a series of health assessments through a process known as Soldier Readiness Processing. US Army Alaska refers to this process as deployment cycle support (DCS). At the Fort Richardson Soldier Centered Medical Home, the DCS health assessment process in cludes, among other things, a check of each Soldiers current hearing ability to determine and document each individuals Hearing Readiness status in the US Army Medical Protection System per Army Regulation 40-501 7 hearing protection in conjunction with the DCS hear ing check. The entire process is fairly intense, with long quickly so that they can go home and decompress with their family and friends. It was during the postdeploy Soldier was asked: what type of hearing protection did you wear in Afghanistan? After asking this question to dicated they had used an identical brand of over-the-ear Over the Ear Tactical Communication and Protection System Use by a Light Infantry (Airborne) Brigade in Afghanistan MAJ Leanne Cleveland, MS, USA

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56 http://www.cs.amedd.army.mil/amedd_journal.aspx (OTE) TCAPS during dismounted operations. Recog nizing this to be a good opportunity for data collection and quality assurance reporting, I prepared a question naire that evening and began handing it out through the rest of the DCS process to any Soldier who reported that he had used this particular OTE TCAPS. In addition to analyzing the subjective data from the surveys, objec tive data (the preand postdeployment hearing tests) of the 56 OTE TCAPS users was compared to the nonTCAPS users. Both subjective and objective outcomes are presented. Subjective Responses: Questionnaire Results Fifty-six surveys were collected from October 13 to Oc tober 21, 2012. All respondents were male. The average age was 29 years. More than 50% were infantry or mor tar team Soldiers (43% and 11% respectively). The sur vey used a Likert scale of 5 simple smiley faces rang ing from a big smile to a big frown, shown in Figure 1, for Questions 1 to 4. The smiley face Likert scale was selected over a numeric scale because the goal was to keep the survey as simple and user-friendly as possible, especially given that the respondents were, for the most part, very sleepy and experiencing jetlag, and were not enthusiastic about the DCS process. The subjective data collected from Questions 1 through 5 of the surveys are as follows: Many responses to Questions 6 and 7 included addi tional information and/or explanations which are synop sized as follows: The 27% of respondents who indicated Other for Question 6 typically included some explanation of how impulse noises, which is encouraging for Army audiolo gists who are searching for incentives to convince Sol diers to wear hearing protection in hazardous noise en vironments. The statistic that 14% of Soldiers indicated that they liked the ability to localize sound is surprising. Situational awareness is key for survivability on the bat tensity, spectral, and timing cues in an open, uncovered ear to determine the location of a sound source. One of the concerns with OTE TCAPS is that covering the ear adversely affects the ability of the wearer to use interaural time delays between the ears and the head shadow effect, which could compromise their ability to localize the origin of dangerous sounds. This is especially true given the microphone placement on the front of the OTE TCAPS, which would give the wearer the impression that all sounds originate directly from the front. How ever, consider the infantry patrol for a moment. Every guard. Each individual is responsible for their assigned sector in front of them, which may explain why ampli fying sounds from directly in front helped this group of Soldiers, primarily infantrymen, and gave them the impression of improved localization ability. the OTE TCAPS became too hot and/or too tight af ter a while, typically after 8 to 12 hours of continuous use. Several surveys described pouring out their sweat 2. How do you rate the clarity of radio communications with the OTE TCAPS? Very Good Good Neither Good Nor Bad Bad Very Bad 75% 25% 0 0 0 OVER-THE-EAR TACTICAL COMMUNICATION AND PROTECTION SYSTEM USE BY A LIGHT INFANTRY (AIRBORNE) BRIGADE IN AFGHANISTAN Figure 1. Smiley face Likert scale used for responses to Questions 1 through 4 on the DCS hearing assessment questionnaire. Very Good Good Neither Good Bad Very Bad Nor Bad 6. What OTE TCAPS feature did you LIKE the most? Radio communications 40% Dismounted operations 19% Localization of sound 14% Other 27% 1. How do you rate the comfort of the OTE TCAPS? Very Good Good Neither Good Nor Bad Bad Very Bad 41% 36% 21% 2% 0 4. Overall, how much do you think the OTE TCAPS helped to improve your warfighter lethality and survivability on the battlefield? Very Good Good Neither Good Nor Bad Bad Very Bad 63% 33% 4% 0 0 3. How clear was spoken language from other Soldiers around you using the external microphone in dis mounted operations (not radio communications)? Very Good Good Neither Good Nor Bad Bad Very Bad 54% 39% 5% 2% 0 5. Did the OTE TCAPS improve your situational awareness? Yes No No Response 84% 14% 2%

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July September 2014 57 pools that collected in the ear cups after extended pe responses in Question 1, in which 77% described the comfort as Good or Very Good. But it is also possible that the comfort issues that arise after 8 to 12 hours of The vast majority of Afghanistan is undeveloped, usu ally only dirt and sand, where Soldiers can go for days without a shower. Sweat will always attract dirt and sand. The combination of sweat and dirt may have made the OTE TCAPS feel like sandpaper being worn on their ears, and yet the 56 survey respondents continued to wear them. The comfort issues described may have more to do with the basic challenges a Soldier sign of the OTE TCAPS. The responses to Question 8 speak to the frugality of experienced Soldiers. Perhaps not all Soldiers need TCAPS. If everybody had one, it could get very costly cal constraint. Then again, every Soldier is exposed to noise just by being in the Army, especially in should initially be given to those who need them the most, but a universal Army-wide or even De partment of Defense-wide TCAPS issue is some thing that almost half of this survey group would like to see. OBJ E CTIV E DA T A: COM PA RISON OF PR EA ND POSTD EP LOYM E NT HEA RING LE V E LS Every US Army Soldiers hearing test data is stored in the Defense Occupational and Environmental Readiness SystemHearing Conservation (DOEH RS-HC) data repository. Queries to that reposi tory for data of the 2,801 Soldiers who underwent postdeployment hearing tests at Fort Richardson from October 13 to October 21, 2012, indicated that 1,068 were non-OTE TCAPS users assigned to the same units as the 56 OTE TCAPS users who re sponded to the questionnaire. Further, comparison of preand postdeployment hearing test data showed a 1,068 non-OTE TCAPS users, as shown in the Table. The Department of Defense uses the Occupational Safe 8 : a change in hearing threshold relative to the baseline audiogram of an average of 10 dB or more at 2000 Hz, 3000 Hz, and 4000 Hz in either ear. Only one of the 56 OTE TCAPS users showed a STS, which is equivalent to a 1.78% STS rate. Figure 2 presents the average preand postdeployment audiograms for the 56 OTE TCAPS users. In contrast, the non-OTE TCAPS group from the same units had a 7.95% STS rate. A 2 analysis compared the STS rate in the group of 56 OTE TCAPS users to the STS rate in the group of 1,068 non-OTE TCAPS users, with the assumption that, given that they were assigned to the same units, a portion of the 2 groups of Soldiers must have gone together on the same missions, and therefore were exposed to a similar level (if not the exact same) of hazardous noise. Results STS rates ( P =.022642), demonstrating that OTE TCAPS did not wear OTE TCAPS. 8. Would you recommend that OTE TCAPS become a unit issue for Soldiers? Yes No In your military occupational specialty (MOS) 98% 2% In another MOS 75% 25% In every MOS 49% 51% 7. What did you DISLIKE the most about the OTE TCAPS? Too hot and/or too tight after extended wearing, typically 8 to 12 hours 60% Wires 7% Other 33% Questionnaire Data Used for 2 Analysis. TCAPS Users Surveyed Oct 13-21 1.78% STS Rate No TCAPS Use Surveyed Oct 13-21 7.59% STS Rate Rest of Brigade No TCAPS Use 10% STS Rate Total STS 1 85 168 254 No STS 55 983 1,509 2,547 Total 56 1,068 1,677 2,801 Predeploy Right Predeploy Left Postdeploy Left Postdeploy Right 500 HZ 2000 HZ 3000 HZ 4000 HZ 6000 HZ 1000 HZ Tone Frequency 20 18 16 14 12 10 8 6 4 0 2 Decibels Hearing Level Figure 2. Average preand postdeployment audiogram results for the 56 questionnaire respondents who indicated that they had consis tently worn OTE TCAPS throughout the deployment.

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx SUMM A RY A ND CONCLUSION The value of this quality assurance data report is that it was initiated at the individual Soldier level, using one of the oldest and most basic OTE TCAPS technologies available. The device that was used by the Soldiers in this report meets ruggedization standards per MIL-STD 810 9 and electromagnetic compatibility per MIL-STD-461 10 Also of interest considering the repeated exposure to of ten considerable perspiration, these OTE TCAPS meet the standard for salt water submersion (3 feet for 30 minutes). 11 Over-the-ear devices do not require special 12 Although the system is technically complex and sophisticated, it is very user-friendly. There are only 2 control buttons on this OTE TCAPS: press and hold one button to turn on or off; press each button in short duration to adjust the volume level to louder or softer. Batteries (AA) are easy Analog compression technology uses a peak clipping strategy to block any hazardous impulse noise. There is no active noise reduction for protection from steady cups provide maximum passive attenuation. There are optional push-to-talk (PTT) devices for radio connec tivity. Soldiers who carry 2 radios can use 2 PTTs, or a single PTT with a toggle switch. Given the current and future TCAPS innovations using smaller, smarter digi tal, custom, and wireless technology, there is consider able potential for advancement in active noise reduction for protection from steady-state noise, as well as digi tal compression for protection from hazardous impulse noise. As the Army continues to endorse a more preven tive approach and emphasis in all aspects of healthcare, the provision of hearing aids for service-related hearing loss may some day become only a minor component of the Army Hearing Program. RE F E R E NC E S 1. Special Text 4-02.501: Army Hearing Program. Fort Sam Houston, Texas: US Army Medical Department Center & School; February 1, 2008. Available at: http://militaryaudiology.org/site/wpcontent/images/st_4_02_501.pdf Accessed Febru ary 17, 2014. 2. Military Application: Combat Vehicle Crewman Headset page. Bose Corporation Web site. Available at: http://www.bose.com/controller?event= view_ static_page_event &url=/professional/military/ crewman.jsp. Accessed February 19, 2014. 3. Defense Update. International, Online Defense Magazine [serial online]. Available at: http://de fense-update.com/newscast/0907/news_27_09_07. htm#quietpro. Accessed February 19, 2014. 4. Peltor No Longer Restricted. PS Magazine online Fort Belvoir, VA: US Army Logistics Support Ac tivity; 2012;715:50. Available at: https://www.logsa. army.mil/psmag/archives/PS2012/715/715-50.pdf. Accessed February 19, 2014. 5. TEA Headsets Awarded TCAPS Order For INVI SIO X50 System. Soldier Systems [serial online]. October 9, 2013; Comms section. Available at: http://soldiersystems.net/2013/10/09/tea-headsetsawarded-tcaps-order-for-invisio-x50-system/ Ac cessed February 19, 2014. 6. Cissna M. Aberdeen Proving Grounds, MD: US Army Public Health Command; email, December 4, 2013. 7. Army Regulation 40-501: Standards of Medical Fit ness Washington, DC: US Dept of the Army; De cember 14, 2007 [revision August 4, 2010]:116[chap 11-4.g]. Available at: http://www.apd.army.mil/pdf Accessed February 20, 2014. 8. Occupational Noise Exposure, 29 CFR 1910.95(g). Available at: https://www.osha.gov/pls/oshaweb/ow adisp.show_document?p_table=standards&p_ id=9735 Accessed February 20, 2014. 9. MIL-STD-810G: Department of Defense Test Method Standard: Environmental Engineering Considerations and Laboratory Tests Washington, DC: US Dept of Defense; October 31, 2008. Avail able at: http://www.atec.army.mil/publications/ Mil-Std-810G/Mil-Std-810G.pdf Accessed Febru ary 20, 2014. 10. MIL-STD-461F: Department of Defense Interface Standard: Requirements for the Control of Electro magnetic Interference Characteristics of Subsys tems and Equipment Washington, DC: US Dept of Defense; December 10, 2007. Available at: http:// snebulos.mit.edu/projects/reference/MIL-STD/ MIL-STD-461F.pdf February 20, 2014. 11. Fallon E. Technical Services, 3M Personal Safety Division; email, 2013. 12. Department of the Army Pamphlet 40-501: Hear ing Conservation Program Washington, DC: US Dept of the Army; December 10, 1998. Available at: http://www.apd.army.mil/pdles/p40_501.pdf. Accessed April 11, 2014. AUTHOR gram US Army-Alaska, Joint Base Elmendorf-Richard son, Alaska. OVER-THE-EAR TACTICAL COMMUNICATION AND PROTECTION SYSTEM USE BY A LIGHT INFANTRY (AIRBORNE) BRIGADE IN AFGHANISTAN

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July September 2014 59 In 1981, The Army Surgeon General established the Health Hazard Assessment (HHA) Program to evalu ate the potential adverse health effects on Soldier users and maintainers of operating military weapon systems. 1 In 1983, Department of Defense Directive 5000.1 (re designated as DoDD 5000.01 2 in 2003) directed all uni formed services to consider health hazards as an integral part of their materiel acquisition process. Also in 1983, Army Regulation 40-10 3 formally established the US Army Center for Health Promotion and Preventive Med icine (USACHPPM) HHA Program. The Army Surgeon General designated the USACHPPM (now the US Army Public Health Command) as the lead agent of the HHA process in 1985, with the primary goal of identifying health hazards, assigning risk, and providing recom mendations to eliminate or control those health hazards associated with the life cycle management of weapons, equipment, clothing, training devices, and other mate riel systems. HEA LTH HA Z A RD ASS E SSM E NT PROGR A M A ND TOXICOLOGY PORTFOLIO risk severity and probability are established using risk assessment codes. The risk assessment code proce dure, adopted from Military Standard 882E 4 is used to quantify health risks to military personnel who will be operating or maintaining Army systems during testing, training, or combat. The following health hazards cat in Army Regulation 40-10 3 : acoustic energy shock biological substances temperature extremes chemical substances trauma radiation energy vibration This article focuses exclusively on toxicity clearances (TC) and the HHA process that deals with chemical sub stances. When a new chemical substance not previously approved for Army use is proposed for use in an item under assessment by the HHA Program, the HHA Pro gram will normally ask the AIPH Toxicology Portfolio (TOX) to conduct a toxicity evaluation of the chemical. The toxicity evaluation leads to the development of a TC for inclusion or reference in the HHA report. When a new chemical is proposed for use not associated with a particular weapon or piece of equipment but generi cally throughout the Army, approval must be obtained via a TC. The Army Surgeon Generals TOX Portfolio at AIPH is described in Army Regulation 40-5 5 cal or material prior to its use helps to ensure the safety of Army personnel. A TC involves a toxicity evaluation of chemicals and materials prior to the introduction into the Army supply system. In some cases, a TC given for one item with a given use scenario may not be ac cepted for an item with the same compound for another use scenario. The materiel developer is responsible for identifying technically feasible materials and requesting appropriate consultation from AIPH TOX Portfolio. In order to initiate the TC, the materiel developer must provide background information concerning the product material along with the request for the TC. The infor mation should include the scope and length of use on the commercial market, human and/or animal toxicity data, a safety data sheet,* reports of any known adverse health effects, and manufacturing use information that will help ascertain the means and magnitude of expo sure to military personnel. The requirement for addi tional toxicity testing will vary with the intended use of the candidate item and its chemical attributes. Examples of items requiring a TC are: solvents energetics repellents pyrotechnics refrigerants metals/alloys explosives pest control agents In many cases, approval for one situation may not apply for a different use if the exposure scenario has changed. Health Hazard Assessment and the Toxicity Clearance Process Mohamed R. Mughal, PhD John Houpt Timothy A. Kluchinsky, Jr, DrPH Occupational Safety and Health Administration Form 20

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60 http://www.cs.amedd.army.mil/amedd_journal.aspx Following the TOX Portfolio review of the pertinent in formation, guidance is issued in the form of a TC memo randum regarding the safe use of the proposed material. It is possible that a TC may not be granted because of toxicological testing is recommended. It is also possible that additional safety and health procedures, equipment, and/or controls are recommended for the safe use of a The HHA Program then reviews the TC developed by ings into the HHA report. A risk assessment code and a mitigation strategy may be developed with a residual risk assessment code assigned by the subject matter ex pert assuming the mitigation strategy is applied. A TC is an extremely valuable tool for the materiel devel oper to make a more-informed decision on the possible use of a chemical or material. It is important to remember The TOX Portfolio does recommend substitute matechemical X a better solvent than chemical Y?) during the research, development, test and evaluation phase of acquisitions. The decision-maker at the requesting or ganization, with appropriate medical health and safety guidance from the AIPH, is responsible for those deci sions and recommendations for a candidate substitute. Formerly, chemicals and materials used in the develop ment and sustainment of Army systems were addressed the implementation of acquisition reform/streamlining throughout the Department of Defense, performance that may have received an initial toxicity review upon development, and those still in effect, are reviewed pe riodically to evaluate newly developed toxicity informa tion. Because numerous products and chemicals without appropriate medical and toxicological evaluation are being proposed as alternatives, the TC is an even more valuable tool for Army leadership responsible for pro curement or acquisition-related decisions. The materiel developer must contact the AIPH TOX Portfolio to request a TC on a chemical or material early in the acquisition process to avoid delays. Direct contact with TOX Portfolio to determine if a TC has been com pleted on a chemical/material is recommended. CONCLUSION Since 1981, the Army HHA Program has provided an invaluable service to capability and materiel developers by providing recommendations designed to eliminate or control health hazards associated with weapon systems and other materiel. The HHA Program has consistently strived to improve its services by providing more mean munity, such as incorporation of the TC process. In the and TOX Portfolio will continue to provide valuable and cost-effective solutions to mitigate health risks associ ated with the use of new and improved materiel systems. ACKNOWL E DG E M E NT e authors thank the following individuals for their contributions to the development of this article: Dr Mark Johnson, Director of the TOX Portfolio ; Dr Wilfred Mc Cain, a Toxicologist in the TOX Portfolio ; and MAJ Sang Lee, MS USA, RE F E R E NC E S 1. Gross R, Broadwater T. Health hazard assess ments. In: Deeter DP, Gaydos JC, eds. Occupa tional Health: The Soldier and the Industrial Base Fort Sam Houston, TX: The Borden Institute; 1993:165-206. 2. Department of Defense Directive 5000.01: The Defense Acquisition System Washington, DC: US Dept of Defense; 2003 [current as of 2007]. 3. Army Regulation 40-10: Health Hazard Assessment Program in Support of the Army Acquisition Pro cess Washington, DC: US Dept of the Army; 2007. 4. MIL-STD-882E: Department of Defense Standard Practice-System Safety Washington DC: US Dept of Defense; 2012. 5. Army Regulation 40-5: Preventive Medicine Wash ington, DC: US Dept of the Army; 2007. AUTHORS All authors are assigned to the Army Institute of Public Health, US Army Public Health Command, Aberdeen Proving Ground, Maryland. Dr Mughal and Mr Houpt are Industrial Hygienists with the HHA Program. Dr Kluchinsky is the Manager of the HHA Program. HEALTH HAZARD ASSESSMENT AND THE TOXICITY CLEARANCE PROCESS

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July September 2014 61 Interest in the subject of chemical and biological warfare has resurged recently. In the United States, the interest had waned substantially due in part to the 1969 deci sion by President Richard Nixon to ban research on the development or use of these weapons for offensive pur poses. 1 Although chemical and biological weapons have always been perceived as potential hazards in the world of asymmetric warfare, the general focus of those con cerned with weapons of mass destruction (WMD) tend ed to be on nuclear weapons. Several events led policy makers, medical planners and others to reconsider this realization that the Soviet Union had continued to de velop a broad range of biological and chemical weapons despite being a signatory of treaties that banned such research and development. The defection of Ken Alibek, a high-ranking Soviet scientist involved in development of biological weapons, revealed a sizeable infrastruc ture in the Soviet Union for development of biological WMD. 2 The dissolution of the Soviet Union raised con cerns among scientists in the west that the substantial stocks of biological agents in the Soviet laboratories could make their way into the hands of terrorists or rogue nations. 3 An earlier event in which a weaponized chemical was used in the subways of Tokyo by a reli gious cult seemed to justify this concern, 4 as did the stat ed interest by other terrorist groups, including Al Qaida, in obtaining and using these weapons. The heavy use of chemical weapons in the Iran-Iraq war of the 1980s also brought attention to these agents, especially with the increased involvement of the United States in the Middle East beginning with Operations Desert Shield and Desert Storm. The suspected presence of chemi cal and biological weapons in Iraq eventually played an important role in the decision to invade that coun try in 2003. Although weaponized chemicals may not Afghanistan, subsequent suspected use of toxic agricul tural chemicals against the students in girls schools of that country 5 in 2010 suggested a willingness by groups hostile to the United States to use such chemicals. More recently, the chemical weapons of the Syrian regime and the suspected use of those weapons in that countrys civ il war have ensured that WMDs have continued to be in the public eye. The United States and other countries are currently working to obtain and destroy the Syrian chemical weapons. Since 2012, the graduate Missouri State University (MSU) Department of Defense and Strategic Studies (DDSS) has taught an online graduate course in chemi cal and biological warfare to students in the universitys Master of Science degree in Defense and Strategic Stud ies. More recently, the course has become a requirement in the Master of Science Degree in Weapons of Mass Destruction Studies, a collaborative program of Mis souri State University and the National Defense Univer sity. The course has evolved over a short time to address the needs of an increasingly diverse group of students. This article describes the development, content, and cur rent status of that course. The purpose is to demonstrate how collaboration between the military, the government, and academia can address the nations need for persons trained in the study of chemical and biological warfare. COURS E HISTORY A ND DE V E LO P M E NT The need for an online graduate course in chemical and of the MSU DDSS. The graduate DDSS was established at the University of Southern California in 1972 and William R. Van Cleave. Based on his experience as a member of the original US delegation to the US-Soviet Strategic Arms Reductions Talks, Professor Van Cleave was concerned that the academic approach to the study of international security issues was overly theoretical, and did not prepare students well for professional ca sequently, Professor Van Cleave designed the Defense and Strategic Studies (DSS) graduate curriculum to in clude the practice of international relations as a main focus of the curriculum. Every course included an un derstanding of the actual practice of international rela tions and the practical application of concepts and theo ry as a student learning goal. While some graduates of the DSS program moved into academic positions, most pursued careers in government, the military, defense in dustry, and the think tank community. Many of the early graduates now hold senior positions in govern ment, industry, or think tanks. For example, the recent Chemical and Biological Warfare: Teaching the Forbidden at a State University CDR (Ret) David M. Claborn, MSC, USN Keith Payne, PhD

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx Secretary of the Air Force, Michael Donley, is a gradu ate of the Defense and Strategic Studies program, as is J. D. Crouch, who served as the Deputy National Security Advisor to President George W. Bush. Professor Van Cleave moved the DSS program to MSU phasize professional education for public service. Upon his retirement in 2005, MSU relocated the entire de partment to Fairfax, Virginia, to enable students to take advantage of the many resources available only in the sources include unparalleled access to professors with deep and pertinent professional experience in govern ment, and readily available internships in government to follow the guidelines established by Professor Van Cleave, that is, professional training for students inter ested in careers in national security. In 2012, DDSS participated in an open competition among universities in the Washington, DC, metropolitan area to work in cooperation with the National Defense University on a 2-year MS degree program in Counter ing Weapons of Mass Destruction (CWMD). The de gree would be for personnel from the Department of De fense. The DDSS of MSU won the competition and was awarded the effort. Following a rigorous application and selection process from among Department of Defense sity CWMD Fellows entered the new DSS CWMD de gree program in August 2012. This initial class included 17 CWMD fellows. These Fellows were sponsored by the Department of Defense, but had to attend classes and complete assignments on their own time. Conse quently, the CWMD degree program will be completed while the Fellows maintain a fulltime work-load for the Department of Defense. Obviously, CWMD Fellows are highly-motivated, serious students. The initial 2012 co hort is a highly-diverse class by all measures, and con sists largely of mid-career civil servants engaged profes sionally in a broad range of the Department of Defenses counter WMD efforts. Almost all members of this ini tial 2012 class already hold graduate degrees, including doctoral degrees in chemistry, biology, microbiology, and medicine. In addition, many Fellows have extensive operational experience. For example, one CWMD Fel low in the initial 2012 class had just completed a tour in Afghanistan as an emergency room physician, and another is playing a pivotal role in current operations associated with chemical weapons in Syria. Few members of the entering class had any previ ous academic background in the areas of the CWMD curriculum, which focuses on international relations theory and practice, nuclear deterrence policy, prolifera tion, arms control, public health issues associated with chemical and biological weapons, counterterrorism, and regional area security studies. The goal of the CWMD Fellows Program is to provide a cadre of professionals within the Department of Defense who have a broad base of expertise in countering WMD. The program is jointly operated by the National Defense University (NDU) and the MSU DDSS. At this writing, it appears that the graduation rate for the initial 2012 NDU cohort (commencement set for July, 2014) will be approximately 80% of the entering class. This is an extremely high graduate degree completion rate compared to national averages. The NDU Fellows who entered the CWMD degree program in the 2013 co hort are progressing with comparable success. The NDU and the DDSS worked collaboratively on developing the curriculum for the masters degree and agreed that a course on chemical and biological warfare was essential to the completeness of the curriculum. A MSU faculty member on the universitys main campus veloping an introductory course to chemical and biolog offered in the spring semester of 2012. As of April, 2014, the course had been taught 5 times, including once dur ing a summer term (the summer term is 8 weeks long as opposed to the 16-week fall and spring semesters.) Ini tially, the course was offered exclusively to students in MSUs regular masters degree in defense and strategic iteration, but the most important changes were made when the course became a requirement for the CWMD Fellowship. At that time, the course reading list was expanded to allow a greater focus on policy aspects of the subject. Nevertheless, the very nature of the biologi cal and chemical agents requires a solid foundation in the epidemiological and toxicological aspects of these weapons. The instructor considered this foundation essential because policy that is based on an erroneous understanding of the weapons or agents can itself be However, the CWMD degree program is not intended to be limited to biologists or medical professionals. As not ed earlier, the original degree program in the DDSS was essentially an international security affairs program in which the students were primarily focused on policy and operational aspects of defense studies. With the advent of the CWMD Fellowship, a broader spectrum of highly experienced students entered the course with the result CHEMICAL AND BIOLOGICAL WARFARE: TEACHING THE FORBIDDEN AT A STATE UNIVERSITY

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July September 2014 63 that the typical class included political scientists, intelli others. This more diverse and experienced student body of the medical or technical aspects of the course with the policy focus of the program. Therefore, new, more further development of the class. After completion of this course, the student will be able to: 1. Identify and describe the most important agents that have been developed for use in chemical warfare and categorize the agents by class. 2. Identify and describe the most important agents that have been developed or used in biological warfare. 3. Discuss the advantages and disadvantages of us ing weapons of mass destruction in the form of chemical and biological warfare from the per spective of the user. 4. Discuss the environmental and logistical prob lems associated with attempts to deploy chemi cal and biological weapons. 5. Describe how response efforts and preparedness can reduce the effects of chemical and biological agents. 6. Identify barriers to the implementation of effec tive response initiatives. 7. Identify important events in the history of chem ical and biological weapons and rank them in or der of importance with regard to impact on the outcome of war, health of the public and military populations, and changes in public policy. 8. Compare and contrast the strategies for the use of chemical weapons as demonstrated during wars of the 20th century. 9. Contrast the potential use of chemical and bio logical agents by terrorists with the historical use of these agents during war, discussing the motivations for use of these weapons by state as opposed to nonstate actors. 10. Describe current events that involve the poten tial or realized use of chemical and biological warfare or terrorism and discuss efforts to elimi nate or reduce the use of the weapons. 11. Discuss the role that technology and globaliza tion may have on the development, dissemina tion, disarmament, and use of chemical and bio logical agents. The objectives require extensive background reading to address issues ranging from the epidemiology of relevant garding the use of weapons of mass destruction. Initially, the course did not use a textbook and the course reading list was gathered from a variety of online sources. The Homeland Security Digital Library proved very useful in obtaining relevant readings. The Borden Institutes Textbooks of Military Medicine (http://www.cs.amedd. army.mil/borden/) were also very useful, especially the sections on the history of development and use of bio logical and chemical weapons. The Borden Institutes textbooks also provide extensive sections on technical, biological, and medical subjects. However, some chap ters were too medically oriented for some students, so only select parts of many chapters were required. The most recent reading list is provided in Table 1. er iterations of the class, The Soviet Biological Weapons Program: A History 6 A large book of over 900 pages, it provides an exhaustive treatment of the subject, but some students thought that its use resulted in an over emphasis on the biological weapons at the expense of the chemicals. The book is inexpensive when bought in electronic form, so portions of it are still used in the course, though only about a quarter of the book will be assigned in future classes. All of the other readings are available online for free either through the Borden Insti tute (online) or the university library. TEA CHING WITH A N ONLIN E MOD A LITY For a variety of reasons (including the fact that the souri, and the universitys graduate DDSS is located in Fairfax, Virginia), the decision was made to offer the chemical and biological warfare course exclusively online. Although this modality expands access to the course for many students, it also presents some limita tions, particularly the potential of reduced interaction between the instructor and students. The university uses the Blackboard teaching software to offer online courses in many departments, so the course was built on this platform. One major advantage of this platform is tures with a recorded voice track. Such lectures would instructor wrote the lectures and recorded them using Microsoft PowerPoint software, then posted them on the

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx Blackboard (Blackboard, Inc, Washington, DC) course website. This technology worked well for disseminating the lectures which were as large as 86,463 kb, includ ing the voice track. Table 2 lists the titles of lectures that were used in the course as presented in the fall se mester of 2013. Lectures varied in length, some were as long as 70 minutes. Subsequent student evaluations of the course called for the use of multiple, shorter lectures that are easier to download, so future iterations of the class will use more but shorter lectures not to exceed 30 minutes in length. As mentioned earlier, the online modality can some times result in limited student participation in distance courses. Students may have minimal involvement espe cially if there is a long period of time between due dates for assignments or tests. For this reason, it is important to encourage multiple interactions between the student and the instructor via the course website. For the chemi cal and biological warfare course, the student is required 4 times each week. The tasks are divided into 3 catego ries: essays, comments/questions, and answers. Each CHEMICAL AND BIOLOGICAL WARFARE: TEACHING THE FORBIDDEN AT A STATE UNIVERSITY Table 1. Required reading list for graduate course in chemical and biological warfare taught as part of the Countering Weapons of Mass Destruction fellowship and degree program for the National Defense University. History and Policy Weapons of Mass Destruction: A Primer. Berstein PI. 2006. Prepared by SAIC, Inc, for the Advanced Systems and Concepts Office of the Defense Threat Reduction Agency. History of Chemical Warfare. Hilmas CJ, Smart JK, Hill BA Jr. Chapter 2; Medical Aspects of Chemical Warfare 2008. Borden Institute. History of Biological Weapons: From Poisoned Darts to Intentional Epidemics. Martin JW, Christopher GW, Eitzen EM Jr. Chapter 1; Medical Aspects of Biological Warfare 2007. Borden Institute. Historical trends related to bioterrorism: An empirical analysis. Tucker JB. Emerging Infectious Diseases 1999, vol 5, no 4, pp 498-504. A farewell to germs: the US renunciation of biological and toxin warfare, 1969-70. Tucker JB. International Security 2002, vol 27, no 1, pp 107-148. The development of the norm against the use of poison: what literature tells us. van Courtland Moon JE. Politics and the Life Sciences 2008, vol 27, no 1, pp 55-77. Chemical Agent Classes Decontamination of Chemical Casualties. Braue EH Jr, Boardman CH, Hurst CG. Chapter 16; Medical Aspects of Chemical Warfare 2008. Borden Institute. Vesicants. Hurst CG, Petrali JP, Barillo DJ, Graham JS, Smith WJ, Urbanetti JS, Sidell FR. Chapter 8; Medical Aspects of Chemical Warfare 2008. Borden Institute. Nerve Agents. Sidell FR, Newmark J, McDounough JH. Chapter 5; Medical Aspects of Chemical Warfare 2008. Borden Institute. Toxic Inhalational Injury and Toxic Industrial Chemicals. Tuorinsky SD, Sciuto AM. Chapter 10; Medical Aspects of Chemical Warfare 2008. Borden Institute. Anthrax. Purcell BK, Worsham PL, Friedlander AM. Chapter 4; Medical Aspects of Biological Warfare 2007. Borden Institute. Plague. Worsham PL, McGovern TW, Vietri NJ, Friedlander AM. Chapter 5; Medical Aspects of Biological Warfare 2007. Borden Institute. Glanders. Gregory BC, Waag DM. Chapter 6; Medical Aspects of Biological Warfare 2007. Borden Institute. Melioidosis. Vietri NJ, Deshazer D. Chapter 7; Medical Aspects of Biological Warfare 2007. Borden Institute. Tularemia. Hepburn MJ, Friedlander AM, Dembek ZF. 2007. Chapter 8; Medical Aspects of Biological Warfare 2007. Borden Institute. Brucellosis. Purcell BK, Hoover DL, Friedlander AM. Chapter 9; Medical Aspects of Biological Warfare 2007. Borden Institute. Q Fever. Waag DM. Chapter 10; Medical Aspects of Biological Warfare 2007. Borden Institute. Smallpox and Related Orthopoxviruses. Jahrling PB, Huggins JW, Ibraham MS, Lawler JV, Martin JW. Chapter 11; Medical Aspects of Biologi cal Warfare 2007. Borden Institute. Alphavirus Encephalitides. Steele KE, Reed DS, Glass PJ, Hart MK, Ludwig GV, Pratt WD, Parker MD, Smith JF. Chapter 12; Medical Aspects of Biological Warfare 2007. Borden Institute. Viral Hemorrhagic Fevers. Jahrling PB, Marty AM, Geisbert TW. Chapter 13; Medical Aspects of Biological Warfare 2007. Borden Institute. Agricultural Terrorism or Warfare State Agro-BW Programs. Millett PD, Whitby SM. Agro-Terrorism: What is the Threat? Proceedings of a Workshop Held at Cornell University, Ithaca, NY, November 12-13, 2000. Available at https://www.hsdl.org/?view&did=3513. Covert Biological Weapons Attacks Against Agricultural Targets: Assessing the Impact Against US Agriculture. Pate J, Cameron G. Agro-Ter rorism: What is the Threat? Proceedings of a Workshop Held at Cornell University, Ithaca, NY. November 12-13, 2000. Available at https:// www.hsdl.org/?view&did=3513. NOTE: Only portions of some readings are required as they may be too medically oriented for some students whose focus is more on policy and international affairs.

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July September 2014 65 week, an essay is assigned based on the lecture of the week and part of the reading list. The essays are at least posed by the instructor. Example assignments or ques tions include: Propose a list of the top 10 most important events in the history of chemical warfare and terrorism in descending order. Justify your choice and the ranking of each event. Describe how the strategies for the use of chemi cal warfare agents by a nation-state might differ from those of a terrorist organization, using ex amples from World War I, the Italian-Ethiopian War, and the Iran-Iraq War. Address purpose, means of dispersal, and limitations as appropriate From the assigned readings, construct a table of 8 important characteristics and variables for 7 bio logical agents. Based on the table that you have constructed, identify the 2 agents in your table that have the most potential in biological warfare. Justify your choices. Explain the concept of the offense-defense bal ance and describe why it affects the decision to use biological weapons. The essays that answer the questions are posted on Thursday of each week. Every student must then se lect 2 essays written by classmates on which to make a thoughtful comment of at least 50 words. At the end of that comment, the student must pose a question to the author of the essay. The comments with questions are due by Monday at midnight. Students must then answer the questions on their own essays that were posed by their classmates; those answers are due by Wednesday night. Thus, students must log onto the site at least 4 supplemental readings; second, to post an essay on the discussion board; third, to read the essays of 2 class mates and to post comments with questions; and fourth, to answer the 2 questions from classmates on their own essays. Even though some of these tasks may take only a few minutes, the multiple interactions between the stu dent and the web site ensure consistent student involve ment throughout the course. Essays are graded by the instructor each week and sent to the students privately. The instructor also reviews the discussion board and comments on students discussions that are based on the comments, questions, and answers. This process is very time-consuming for the instructor but the routine of the class encourages maximum, sustained student partici pation. New assignments are posted weekly. INDIVIDU A L PROJ E CTS As with most graduate level courses, the faculty saw a need for an individual project that would provide the students with the ability to explore topics of particular interest to them. The project encourages students to be come familiar with the scholarly and technical literature of chemical and biological warfare and to become more were thus given a choice between doing an annotated bib liography on an instructor-approved subject, or a news journal in which the student summarized the content of 50 news articles on chemical and biological warfare that had been published in the last 25 years. Although the student could write the annotated bibliography on any approved subject, several were suggested by the instruc tor and most students chose to write the bibliographies on the suggested topics. The instructor-suggested topics are listed in Table 3. The suggested topics were provided and to encourage a degree of self-direction. The bibli ography had to have a minimum of 20 annotations from reliable sources of literature. Some students, however, wanted to become more familiar with current events as reported in the news media. Those students opted for the 50-article news journal. In fact, in the latest iteration of the class, the majority of the students chose the news journal option. EV A LU A TION OF STUD E NTS The students were evaluated primarily on the essays that were submitted weekly, though some credit was also given for participation in the class discussion board. Es says were worth 50% of the score, and discussion 10%. Table 2. Online lectures used in class on chemical and biologi cal warfare taught by Missouri State University for the National Defense Universitys Countering WMD Fellows program. Course Introduction, Procedures and Expectations Basic Biology for the Non-biologist Interested in Chemical and Biological Warfare Agents: Toxicology Basic Biology for the Non-biologist Interested in Chemical and Biological Warfare Agents: Epidemiology History of Chemical and Biological Warfare Introduction of Chemical Warfare Agents: Chemical Classes Toxicology of Neurotoxins and Applications in War The Vesicants Strategies for Use of Chemical Agents in WWI, the Italy-Ethiopia War, and the Iran-Iraq War Toxic Industrial Chemicals and Materials: Potential in War and Terrorism Decontamination of Chemical and Biological Warfare Agents Concepts of Biological Warfare Agricultural Terrorism and Warfare NOTE: All lectures are PowerPoint presentations delivered through the Blackboard online education platform. Each lecture has a voice track and length varies from 15 to 70 minutes.

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66 http://www.cs.amedd.army.mil/amedd_journal.aspx The individual project (annotated bibliography or news posed primarily of objective questions accounted for the the course when it became part of the CWMD fellows program to ensure a more thorough knowledge of the exam questions came primarily from the readings and from weekly comments on the assignments provided by the instructor. STUD E NT EV A LU A TIONS OF TH E COURS E Initial student evaluations of the course were generally, though not universally, favorable. The most recent stu dent evaluations have been quite positive. Earlier, some presentation of the course. One consistent concern has been the online format which some students do not like, the online discussion board using comments and ques tions from the students themselves to be the least advan tageous part of the course. On a scale of 1 to 5 with 5 being excellent, the discussion board has been the only component to receive a score of less than 4. The news journal that many of the students complete as a project is routinely very popular. Students report that it provides them with a systematic opportunity to become familiar with current events. LE SSONS LEA RN E D After 5 iterations of the course, several improvements have been made based on student evaluations and other observations. Some of the lessons learned are discussed below: Student understanding and participation is im proved when the student must log onto the course web page multiple times each week. Otherwise, the student may lose track of class subject matter and discussion material. The online modality is generally suitable for the chemical and biological warfare subject, but some students require additional instruction on the use of online technology such as the instructional software. ferent geographical area. Also, the online modality is potentially susceptible to plagiarism and other forms of academic dishonesty. Instructors must be well-versed in ways to prevent and detect violations. Some review and instruction in the biology and toxicology of chemical and biological agents is es sential, especially for those who do not have aca demic backgrounds in science. The amount of re view varies with each iteration of the class. One way to address this issue is to have a series of short online review lectures that are available to those students in need of the review. Students are held responsible for the information in the lectures but students with backgrounds in biology, chemistry, or medicine usually need only a cursory examination of the material. The academic and professional backgrounds of stu dents in this course vary greatly, probably more so than in many other classes. Some exhibit a very but may have little knowledge of others. Other stu dents may initially have almost no understanding of the material. The use of student biographies in the the opportunity to gauge the range of knowledge and experience within the class. The biographies can also help direct student discussions. Students with particular expertise may be asked to address a subject in a special online discussion board. The student biographies can also allow the instructor course to address areas of particular interest to a CHEMICAL AND BIOLOGICAL WARFARE: TEACHING THE FORBIDDEN AT A STATE UNIVERSITY Table 3. Suggested topics for the annotated bibliography required as part of the course Chemical and Biological Warfare in the Department of Defense and Strategic Stud ies, Missouri State University. Agroterrorism Domestic Terrorism and the Chem-Bio Threat The Role of Chembio in the Decision to go to War in Iraq Tularemia as a Bioagent Bhopal as a Model of Chemical Agent Terrorism Decontamination of Equipment and Sites Potential Chemical Weapons Use in the Middle East Detection of Chemical and Biological Agents Toxicology of Blood Agents Dispersal Techniques For Chem/Bio Agents Allegations of Chem/Bio Warfare in WWII Treaties and Chem/Bio Weapons Business and Organizational Continuity History of the Soviet BW/Chem Program Anthrax as a Bioagent Smallpox as a Bioagent Decontamination of Personnel Emerging Diseases as Potential Bioagents Medical Preparedness For a Chemical Event Toxicology of Vesicating Agents Biotoxins as Chemical/Biological Agents History of Incapacitating Agents The Role of Immunization in Biodefense Disarmament and Chem/Bio Weapons

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July September 2014 67 particular cohort of students or to provide addition al leveling material prior to introducing an unfamil iar subject. CONCLUSION The graduate course on biological and chemical warfare taught by the Missouri State University Department of Defense and Strategic Studies in conjunction with the National Defense University Countering Weapons of Mass Destruction Fellows program offers a unique combination of perspectives, from the academic to the military to the political and diplomatic. Teaching with such a broad range of perspectives to a group of students with an even broader range of education and profes sional experience can be challenging. The ability to ef people with cross-disciplinary education and the ability to operate in diverse environments. Recent events have described herein is a part of a larger degree program that includes courses in nuclear strategy, arms control, counter-proliferation, intelligence-counterintelligence, terrorism, ethics, defense policy, and other subjects. The content of the course will, of necessity, evolve to address the changing issues of terrorism, insurgency, diplomacy, globalization, and war, but it will hopefully contribute to a cadre of professionals with the backgrounds, critical thinking skills, and education to protect the nation from the threat of chemical and biological agents and other weapons of mass destruction. RE F E R E NC E S 1. Tucker JB. A farewell to germs: the US renunciation of biological and toxin warfare, 1969-70. Int Secur 2002;27(1):107-148. 2. Alibek K Biohazard: The Chilling True Story of The Largest Covert Biological Weapons Program in the World Told From the Inside by the Man Who Ran It. New York: Random House; 1999. Available at: http://www.nlm.nih. gov/nichsr/esmallpox/biohazard_alibek.pdf. Accessed April 22, 2014. 3. Garret L. Biowar. In: Betrayal of Trust: The Collapse of the Global Public Health System New York: Hyperion; 2000:486-550. 4. Hoffman B Inside Terrorism. New York: Columbia University Press; 2006. 5. Nordland R. Poison gas used to sicken schoolgirls, Afghans say. New York Times September 1, 2010:A8. Available at: http://www.nytimes.com/2010/09/01/world/asia/01gasattack.html?_r=0. Accessed April 22, 2014. 6. Leitenberg M, Zilinskas RA. The Soviet Biological Weapons Program: A History Cambridge, MA: Harvard Uni versity Press; 2012. AUTHORS CDR (Ret) Claborn, a career US Navy medical entomologist, is an Assistant Professor of Public Health and Homeland cal and biological warfare course described in this article. Dr Payne is the Head of the Graduate Department of Defense and Strategic Studies, Missouri State University (Wash ington Campus). He is the Director of the Countering Weapons of Mass Destruction Fellows Program for Missouri State University. Previously, Dr Payne served in the Department of Defense as the Deputy Assistant Secretary of Defense for Forces Policy.

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68 http://www.cs.amedd.army.mil/amedd_journal.aspx Military preventive medicine is, in fact, the product of military economic, and political movements and forces in the civilian world. Therefore, the evolution of preventive medicine in the United States Army cannot be considered as an isolated affair. Rather, it is to be regarded and understood as the result of the interaction between civilian and military knowledge and opinion as to what should be done, and how to do it, to preserve the health of soldiers. BG Stanhope Bayne-Jones 1 The words of BG Bayne-Jones stand the test of time, providing a wonderful perspective on the subject of pub lic health law. This area of law is truly about the interac tion between the military and civilian world, but so of ten, leaders and clinicians do not understand its breadth. They often think of public health law in terms of public health emergency law, but that is just a very small part within this area of law. Public health law covers so many areas which have made headlines in recent years, such as childhood obesity and its effect on chronic disease, the controversial reduction in drink sizes for carbonated beverages in New York City, municipal bans on foods in restaurants in Chicago, nosocomial infections and their effect both inside and outside the hospital setting, along with national pharmaceutical shortages to name a few. While I certainly do not expect leaders and clinicians to heightened sensitivity to this area of the law is critical. TH E FUND A M E NT A LS In his text, Public Health Law: Power, Duty, and Re straint 2 Professor Lawrence Gostin notes that the legal powers and duties of the state are to assure conditions for people to be healthy, and the limitations on the power of the state to constrain autonomy, privacy, liberty, pro priety, or other legally protected interests of individuals for the protection or promotion of the community health. State is a general term of government which does not such, state can refer to the federal, state, county, bor ough, parish, township, and/or municipal governments. Because each refers to a different level of government, it is important to be clear whether the reference is to the federal government, especially when dealing with military issues, or the government of, or within, a partic ular state in the Union. There is a relationship, however, between the federal and state governments referred to as federalism. Federalism can sometimes create a tension between the federal and the state levels of governments because each of the 50 states and their subordinate gov ernments possess substantial, independent legal author ity which is still subject to the supremacy of federal au thority, to the extent it exists in regard to certain matters. Often, the authorities overlap and the astute leader and clinician will embrace that overlap and facilitate a sense of teamwork at all opportunities despite any counter in attitudes exist between different levels of government. Overcoming these attitudes is a challenge. SOURC E S OF LA W Constitution. It is the source of all legal authority for the federal government and state governments. Each state has its own constitution, and subordinate levels of gov ernment often have their own legal sources of govern ment such as a charter or statute. Since they all differ, their style of government may be different as well, yet all fall under the authority of the US Constitution. The US Constitution is truly the supreme law of the land, ex The powers not delegated to the United Sates by the Con stitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people. In other words, if the US Constitution does not contain a provision dealing with a certain matter, that matter is reserved to the states; those powers are often referred to as police powers. There is no mention of public health in the US Constitution, so, as a result, public health has normally been the primary responsibility of the states, and public health law has normally been a creature of state and local governments. Despite that responsibility, the federal government has often asserted its authority over public health-related activities through its interstate I, Section 8, of the US Constitution. These powers ex plain such policies in the past as national speed limits An Introduction to Public Health Law for Leaders and Clinicians

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July September 2014 69 and tobacco taxes, seemingly local matters controlled tension under the concept of federalism. Statutes and regulations are outgrowths of the US Con stitution and the respective state constitutions. The constitutions give the US Congress and the various state legislatures the power to pass laws in the form of statutes. Federal agencies and state agencies then write regulations that implement the statutes. These statutes can affect public health at the federal, state, and local levels. For example, Congress passed statutes that cre and powers. It also created explicit regulatory agencies nonregulatory agencies like the Centers for Disease created agencies with regulatory and nonregulatory powers and those same state legislatures delegated simi lar regulatory authority to lower levels of government to create entities such as departments of public health which possess similar regulatory powers but only with in their local jurisdictional limits. This mix of federal, state, and local laws and regulations can be a challenge federal military installation surrounded by several local and state jurisdictions. Everyone may or may not be op erating in the same or similar manner in regard to public health, yet each is certainly in compliance with federal law, except that military installations must comply with their respective agency and department regulations as one if everyone from all the levels of government come together to work through the issues. without mention of the common law. Local, state, and federal courts determine the guilt of accused criminals, resolve private law disputes between individuals, and review actions of agencies enforcing civil laws such as those addressing public health. In general, lower courts follow the decisions of higher courts, and state courts review state laws to determine if they violate the state or federal constitutions. Federal courts review the constitu tionality of state and federal laws, and the US Supreme Courts decisions bind all state and federal courts. The federal courts and most state courts use common law precedent which is critical, especially when it involves decisions that affect public health matters. That prec edent established by some decision will then bind us in terms of what we can or cannot do in a public health scenario. JA COBSON V MA SS A CHUS E TTS, A LA NDM A RK CA S E Jacobson v Massachusetts and the foundation of public health common law. This on a state statute compelling vaccinations of residents against smallpox after a recent smallpox outbreak in Upon the principle of self-defense, of paramount neces sity, a community has the right to protect itself against an epidemic of disease which threatens the safety of its members. With its decision in support of the law, the US Supreme Court began our modern constitutional analysis of dis Use of police powers for public health concerns. Delegation of certain authorities to health agen cies and other government subdivisions. Use of actions limiting liberty for well-estab lished public health interventions. ancing of public good vs individual rights, a concept which leaders and clinicians will have to understand as they face future public health matters. ETHICS A ND TH E LA W laws are often broadly framed, leaving much room for administrative discretion about when to use public health authority and about which intervention is more ethically appropriate when more than one alternative course of ac tion is legally permissible. 3 Public health law provides authority, limitations on state power, and incentives and disincentives for behavior. It is very formal, focusing on statutes, regulations, and court decisions as previously described. Unfortunately, law does not always cover every situation or every issue which arises. Sometimes, less formal actions and deci sions must be taken based on norms, values, profession al codes, and previous experience. In other words, some times the law will simply not have the clear answers to the questions posed and a more informal but deliberate Federal executive branch employees must conduct them selves within the parameters of executive branch ethics.

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70 http://www.cs.amedd.army.mil/amedd_journal.aspx In the military, the Joint Ethics Regulation 4 supple ics rules for government employees are really standards standards. Norms and morality address the rights and wrongs that are widely shared by society. Some are uni versal, while others are particular to certain communi then require balancing. In many ways, balancing norms and moral claims is similar to the process leaders and clinicians use when balancing public good versus indi vidual needs; it could be characterized as a public health or losses, leaders and clinicians identify, weigh, and bal ance the moral interests that are at stake. people take different ethical approaches such as utili tarianism, liberalism, or communitarianism, to name a to guide professionals within their practice and profes professionals and those they serve. For example, federal executive branch employees follow the Standards of Ethical Conduct for Employees of the Executive Branch ship Society. 5 COMMON PUBLIC HEA LTH ISSU E S of his duties are still necessarily concerned with law with the extent of their powers and duties, but also with the limitations imposed upon them by law. Emergencies Generally, emergency declarations are issued after a public health event begins. Some states have adopted statutes that provide very detailed standards for actions in a public health emergency. Some declarations limit police powers while others are silent, which may give local health departments broad powers under a states police powers. The US Constitution gives the President broad powers to manage national security threats like bioterrorism, and the President can also react to a states request for emergency support. The Federal Emergency by providing emergency housing, water, and other sup plies and loans. Of great interest is the development of between the states. These contracts, administered by state emergency management agencies and activated by governor-declared emergencies, allow states to share personnel and other resources across state boundaries. state-state relationship which can be established with or without federal assistance. Surveillance, Reporting, and Personal Privacy In the spirit of federalism, state and local governments conduct most communicable disease surveillance, in vestigation, and intervention under their police powers, while the federal government has the responsibility in controlling diseases related to goods moving in interstate commerce, such as food. Both ideally cooperate when disease threats cross state lines and authorities overlap. cal governments report this information to the CDC, which acts as a national clearing house for state disease reports looking for patterns, tracking emerging dis regulate state or local government public health entities. cupational diseases based on its authority legislated as There is no common law physician-patient privilege. There was no general right of medical privacy until pas ever, personal privacy is not absolute when it comes to Whalen v Roe porting of narcotics prescriptions to the New York State protected rights. States can require access to records as a condition for medical and facility licensure. The federal government also requires access to records as a condi tion for participating in federal payments programs. Fi nally, even when individuals or businesses are not regu lated by a state or the federal government, a court order may grant access to information otherwise inaccessible. Environmental Health Leaders and clinicians also must consider environmen ronmental law and public health law 2 separate legal AN INTRODUCTION TO PUBLIC HEALTH LAW FOR LEADERS AND CLINICIANS

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July September 2014 71 environmental health regulation was done by state and These laws may in fact preempt state laws. Then again, the federal laws set minimum standards which are im plemented and enforced by the states. In some instances, the state standards may be stricter than the federal stan dards or incorporate a wider scope. In addition, federal tal departments along with large city and county health departments have roles in the regulation of environmen and cooperation among them is vitally important. Occupational Health two cannot help but overlap. When there is workplace injury, states have workers compensation laws that are administered by state agencies rather than the courts to provide limited compensation to employees. The fed eral equivalent is the Federal Employees Compensation compensation to civilian federal employees for work cient incentive to reduce occupational injury, so it cre and researches and funds programs to reduce work-re sets and enforces standards for workplace safety and regulations. CONCLUSION health law, but hopefully it has given the reader a sense of the extent and depth of this incredible area of the law. Like the public health sector itself, this area of the law is constantly growing and constantly changing. Public health law is by no means static. It is a challenging area of law which is regularly, invariably addressing new is sues. The necessity for public health and legal profes sionals well-versed in both the substance and nuance of public health law is growing, with no end in sight. ACKNOWL E DG E M E NTS I thank University Professor Lawrence O. Gostin of the Georgetown University Law Center and Professor John D. Blum of the Loyola University Chicago School of Law for their mentorship and support in the development of my knowledge and capabilities in the area of public health law. RE F E R E NC E S 1. Bayne-Jones S. The Evolution of Preventive Medi cine in the United States Army, 1607-1939 Wash history.amedd.army.mil/booksdocs/misc/evprev/ 2. Gostin LO. Public Health Law: Power, Duty, Re straint Press; 2008. 3. Law in Public Health Practice 4. Department of Defense 5500.7-R: Joint Ethics Regulation 5. Public Health Law 3rd ed. New York, AUTHOR Texas.

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72 http://www.cs.amedd.army.mil/amedd_journal.aspx An ounce of prevention is worth a pound of cure. Benjamin Franklin 1 TH E ME DIC A L COST AVOID A NC E MOD E L ICD -9 AN A LYSIS TOOL 3 2 When t t = + h + l + + d Using the Army Medical Cost Avoidance Model to Prioritize Preventive Medicine Initiatives 2

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July September 2014 73 Medical Treatment Cost. Lost Time Cost. a b c Fatality Cost. 6 Disability Cost. 7 TH E MC A M IN ACTION: AN ICD -9 AN A LYSIS FOR TH E SA F E PA TI E NT HA NDING A ND MOBILITY PROGR A M [ % ] [ % ] 11 11 12 Table 1. The MCAM Medical Cost Components, Definitions, and Descriptions. Cost Component Description C C h C C f C

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx Guidelines for Design and Construction of Healthcare Facilities 13 16 17 2 TH E ICD -9 AN A LYSIS TOOL US E R INT E RF A C E Calculate Cost Avoidance Details Print Results USING THE ARMY MEDICAL COST AVOIDANCE MODEL TO PRIORITIZE PREVENTIVE MEDICINE INITIATIVES

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July September 2014 75 TH E ICD -9 CA S E AN A LYSIS REP ORT 3 Year Average (FY 2010 2012) ICD-9 Description, Short Case Count Average Cost/Case Incidence 7241 37 $364 2.87 7242 181 $451 14.06 7244 23 $1,228 1.75 7245 66 $318 5.10 7248 27 $332 2.10 Accumulative incidence per 100 NOS indicates not otherwise specified. Figure 1. MCAM ICD-9 Analysis Tool user interface. Cost Details Lost Time: $9,085,936 Clinic: $309,206 Hospital: $2,308,938 Disability: $0 Fatality: $0 Lifecycle Cost $11,704,080 Ok Model Background Input Guides

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx SUMM A RY RE F E R E NC E S International Figure 2. The MCAM ICD-9 Case Analysis Report. User Inputs Grand Total: $14,999,480 Project Costs ($): $750,000 Net Grand Total: $13,499,480 Return on Investment USING THE ARMY MEDICAL COST AVOIDANCE MODEL TO PRIORITIZE PREVENTIVE MEDICINE INITIATIVES

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July September 2014 77 Online Guidelines for Design and Construction of Health Care Facilities Ergonom ics Inj Prev Stud AUTHORS

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx The Medical Education and Training Campus (METC) was established as part of the 2005 Base Realignment and Closure Commission legislation requiring the Air Force, Army, and Navy to collocate enlisted basic and (most) specialty medical training at Joint Base San An tonio Fort Sam Houston, Texas. The METC achieved initial operating capability on June 30, 2010, becom ing fully operational on September 15, 2011. Currently, METC has 9 academic Departments and 51 programs. More than 21,000 Air Force, Army, Navy, Marines, Coast Guard, and international students graduate from METC each year. An average of 7,000 students are on campus at a given time. The Public Health Specialist Program, along with the Behavioral Health Program, falls under the Depart ment of Public Health. Originally named the Preven tive Medicine Program, the name was changed to the Public Health Specialist Program in the fall of 2013 to better align the training with civilian equivalents. The program graduates Army Preventive Medicine Special ists (Military Occupational Specialty 68S) and Navy Preventive Medicine Technicians (Navy Enlisted Clas tive Medicine Program graduated on October 26, 2011. Since then, more than 1,000 students have graduated from the program at METC. In 2013, the program initiated a major curriculum over haul to improve the quality of the training by updating courses, better incorporating technology into instruc tion, and realigning some courses. The new curricu lum is scheduled for implementation in the summer of curriculum for the Public Health Specialist Program at dents, faculty, and the military services. OV E RVI E W The Public Health Specialist Program consists of a con course begins with the consolidated phase, during which training, covering a variety of topics required by both services. Once the consolidated portion of the training the Army and Navy respectively. Army students have current curriculum, the American Council on Education recommends that award of 9 undergraduate credit hours for Army students and 12 hours for Navy students. Entomologist and one Environmental Science and En Navy NCOs. The Program Director is either an Army services. There are 7 courses within the consolidated portion of the training: Introduction to Preventive Medicine, Medi cal Threat, Food Service Sanitation, Aspects of Water, Entomology, Operational Preventive Medicine, and De ployment Environmental Surveillance Program. Intro duction to Preventive Medicine provides students with a brief overview of Preventive Medicine and sets the stage for the remainder of the training. The Medical Threat course prepares students to prevent and reduce disease and injury in operational settings and to communicate Service Sanitation prepares students to inspect food ser vice operations and provide consultation to food service Sanitation Course, students have the opportunity to earn Association. During Aspects of Water, students learn to test water for a variety of uses, interpret those re that water is safe for its intended use. The Entomology course introduces students to the basics of pest control completion of this course, students earn Department The Public Health Specialist Program at the Medical Education and Training Campus

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July September 2014 79 lowing Environmental Protection Agency pest control categories: Right-of-Way Pest Control; Industrial, In stitutional, Structural, and Health-related Pest Control; and Public Health Control. The Operational Preventive ment procedures used during disaster and humanitarian relief missions, base camp assessments, and medical threat assessment. Finally, the Deployment Environmen tal Surveillance Program prepares students to perform air, water, and soil surveillance, and document potential adverse health exposures in an operational environment. Health, Health Physics, Industrial Hygiene (IH), and a Situational Training Exercise (STX). Army Public Health provides students with an understanding of Army programs related to health and wellness, including the Military Vaccine (MILVAX) program, sexually trans mitted disease prevention, and epidemiological investi gations. The Health Physics course provides students an introduction to chemical, biological, radiological, and nuclear event response. In the IH course, students learn Industrial Hygiene from the Army Medical Department Army students is a capstone STX. The STX is scenar io driven and requires students to draw from all of the health threats in the given scenario. ministration, Communication, Biostatistics, Epidemiolo gy, Microbiology, Parasitology, Immunization Programs, Occupational Safety and Health, Shipboard Preventive Medicine, Environmental Sanitation, and a Final Evalu ation Exercise (FEX). Public Health Administration pro vides Navy students with a basic understanding of how effectively communicate public health messages in their future assignments. Biostatistics gives students an intro duction into the fundamentals of statistics. Epidemiology covers the principles of disease investigation, reporting, and prevention. The Microbiology course examines the impacts that microorganisms have on humans and the environment. Parasitology introduces students to para sites that can affect human health and their epidemiol ogy. The Immunization Programs course provides stu dents with an understanding of the MILVAX program and prepares them to manage immunization programs in their future assignments. Occupational Safety and Health provides an introduction to the Navys Occupa tional Safety and Health Programs. Shipboard Preventive Medicine covers potable water supply requirements for mental Sanitation covers sanitation and infection control, Navy students. The FEX is scenario driven and requires students to synthesize the information that they learned throughout the program to address real-world situations, preparing written and oral products for evaluation. RE VIS E D CURRICULUM gram will begin teaching the revised curriculum, which is designed to increase the individual Soldier or Sailors readiness to perform their mission upon graduation. While many of the individual courses have the same titles in the revised curriculum, the entire program was carefully reviewed for accuracy of content, currency of materials, and synchronization between test questions and lesson objectives. Ensuring that the program ad List (CTL) for Preventive Medicine Specialists and the Medicine Technicians was a major consideration in de veloping the new curriculum. Once the training require the CTL and JDTA, they were cross-referenced to de termine which can be taught in a consolidated environ ment and those that are so unique to one of the services target higher levels of learning in both the cognitive and psychomotor domains than presented by the earlier many of the courses and help to ensure that better pre pared students are graduating from the program. in the consolidated phase was shifted to generate a bet tion to reduce redundancy. As a result, the consolidated instructional hours; the Army phase will decrease from 208 to 180 instructional hours; and the Navy phase will parison of the current and revised curriculum in terms of hours spent in each course and the order of courses is presented in the Table. After implementation, the new curriculum will be presented to the American Council

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80 http://www.cs.amedd.army.mil/amedd_journal.aspx on Education for review to determine the number of un dergraduate credits earned by Army and Navy students. and Communication are added to the consolidated por tion of the training. Military Public Health brings mate tions of the program together to provide Army and Navy students an overview of public health in the military, and better sets the stage for the courses that they will of the program to the consolidated phase to provide both Army and Navy students with the fundamentals of pre cess throughout the program as well as in their careers. In an effort to better streamline the program, the Medi cal Threat and Operational Preventive Medicine courses are combined into a single course named Operational Preventive Medicine. The order of courses was adjusted courses that build on each other grouped together. The order of courses is shown in the Table. The Army Public Health course is removed from the Ar ulum moved to the Military Public Health course in the consolidated phase. Health Physics and Industrial Hygiene remain in lum, with students still receiving the Basic AMEDDC&S following completion of the latter course. The STX now conducted on Ft. Sam Houston will transition to a Field Training Exercise (FTX) which will be conducted at Camp Bullis, Texas. slightly shorter under the revised curricu lum, with the Communication course shift ed to the consolidated curriculum. Further more, the new curriculum will incorporate Shipboard Pest Management, which has not been previously taught at METC, into the Shipboard Preventive Medicine course. In order to better prepare our Sailors for their Christi Naval Air Station to give Sailors an opportunity for hands-on training in some Preventive Medicine. COMM E NT Consolidated training at METC presents a wide array of at METC, curriculum should be developed that incor porates consolidated training as much as possible while balancing the unique needs of each service. The Public Health Specialist Program presents an effective, highquality, academic program that strives to exploit the ad vantages of training within the METC environment. By far, the greatest advantage of the consolidated Public Health Specialist Program at METC is that it prepares our students from very early in their careers to under During Operations Iraqi Freedom and Enduring Free an increasingly joint environment. For many of our ser another service culture was in the high stress, deployed environment. The establishment of METC enabled this experience to become part of the early indoctrination of our service members into military medicine. During the consolidated portion of training, Army and Navy students begin each day reciting in turn the Sol diers Creed and the Sailors Creed and singing both Current and Revised METC Public Health Specialist Program Curricula. Phase Current Curriculum Revised Curriculum Consolidated Introduction to Preventive Medicine Medical Threat Food Service Sanitation Aspects of Water Entomology Operational Preventive Medicine Deployment Environmental Surveillance Program Introduction to Preventive Medicine Military Public Health Communication Food Service Sanitation Aspects of Water Deployment Environmental Surveillance Program Operational Preventive Medicine Entomology Army-specific Army Public Health Health Physics Industrial Hygiene Situational Training Exercise Health Physics Industrial Hygiene Field Training Exercise) Navy-specific Communication Public Health Administration Biostatistics Epidemiology Microbiology Parasitology Immunization Programs and Vaccines Shipboard Water Sanitation Occupational Safety and Health Environmental Health Final Evaluation Exercise Public Health Administration Microbiology Biostatistics Epidemiology Parasitology Immunization Programs and Vaccines Occupational Safety and Health Environmental Sanitation Shipboard Preventive Medicine Navy Final Evaluation Exercise THE PUBLIC HEALTH SPECIALIST PROGRAM AT THE MEDICAL EDUCATION AND TRAINING CAMPUS

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July September 2014 81 Anchors Aweigh and The Army Goes Rolling Along together across services on projects, in study groups, and as teammates. They are taught by members of each service, getting different perspectives and experiences to draw from in their own careers. By the completion of the consolidated courses, they are a cohesive team in which students better understand the culture of each in the future. nature of the program for many of the same reasons. Regardless of the uniform that an individual instruc tor wears, all instructors in the program are responsible for teaching and mentoring both Army and Navy stu dents at the start of their careers in preventive medi to communicate effectively within each service culture. By the time program faculty depart METC, they have a solid understanding of both the similarities and the dif ferences of the military services and are themselves bet ter prepared to serve in joint environments in the future. Public Health Specialist Program to both students and faculty, it is clear that the nature of the program will ulti and Soldiers who have a less parochial view of their role within the military. As more service members graduate from the academic programs at METC and begin their ed training will continue to grow. By developing curri much as possible, the Public Health Specialist Program at METC is one small piece of the larger effort to im prove integration of the capabilities and interoperability of military services across the full spectrum of Military Medicine. ACKNOWL E DG E M E NT e authors thank the following individuals for their contributions to the development of this article: HMC Paul Langrehr, USN; SFC Joseph Barton, USA; HMC Kelly Wallen, USN; SSG Mark Almendares, USA; SSG Danielle Maddox, USA; and SSG James Stephens USA. AUTHORS MAJ Colacicco-Mayhugh is Director, Public Health Specialist Program, Department of Public Health, Medi cal Education and Training Campus, Joint Base San An tonio Fort Sam Houston, Texas. LT Blaesing is the Navy Service Lead, Public Health Specialist Program, Department of Public Health, Medi cal Education and Training Campus, Joint Base San An tonio Fort Sam Houston, Texas. Carolina. Medical Education and Training Campus Public Health Specialist Program students performing entomological surveillance.

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82 http://www.cs.amedd.army.mil/amedd_journal.aspx The United States Army uses a community coalition approach called community health promotion councils (CHPC) as a strategic platform to manage the Army Public Health System. The Army is organized across functional chains of command. The Army Public Health System has subject matter experts on various public health concerns in these different systems. Assets can be found as a part of the medical system, the installation management system, or as a part of tactical operations at the mission level. Each of these systems plays a part in managing the overall public health system for the Army installation. The driving force for the standardization of integrating the Armys Public Health System through the CHPC is Army Regulation 600-63 1 promotion as: any combination of health education and related or ganizational, political, and economic interventions de signed to facilitate behavioral and environmental chang es conducive to the health and well-being of the Army community. 1(p6) Community health promotion councils are designed to manage a coordinated approach to local public health at Army installations and integrate health promotion and disease prevention into the Armys business practices. Because CHPCs are essential to the Armys strategy to Managing Public Health in the Army Through a Standard Community Health Promotion Council Model Anna F. Courie, RN, MS Moira Shaw Rivera, PhD Allison Pompey, DrPH, CPH ABSTR A CT Context: Public health processes in the US Army remain uncoordinated due to competing lines of command, funding streams and multiple subject matter experts in overlapping public health concerns. The US Army (CHPCs) as an effective framework for synchronizing and integrating these overlapping systems to ensure a coordinated approach to managing the public health process. Objective: The purpose of this study is to test a foundational assumption of the CHPC effectiveness theory: the 3 features of a standard CHPC modela CHPC chaired by a strong leader, ie, the senior commander; a full time health promotion team dedicated to the process; and centralized management through the USAPHC will lead to high quality health promotion councils capable of providing a coordinated approach to addressing public health on Army installations. Design: The study employed 2 evaluation questions: (1) Do CHPCs with centralized management through the USAPHC, alignment with the senior commander, and a health promotion operations team adhere more closely to the evidence-based CHPC program framework than CHPCs without these 3 features? (2) Do members of standard CHPCs report that participation in the CHPC leads to a well-coordinated approach to public health at the installation? Conclusions: The results revealed that both time (F (5,76) =25.02, P <.0001) and the 3 critical features of the stan dard CHPC model (F (1,76) =28.40, P <.0001) independently predicted program adherence. Evaluation evidence supports the USAPHCs approach to CHPC implementation as part of public health management on Army installations. Preliminary evidence suggests that the standard CHPC model may lead to a more coordinated ap proach to public health and may assure that CHPCs follow an evidence-informed design. This is consistent with past research demonstrating that community coalitions and public health systems that have strong leadership; regulations function more effectively than those without. It also demonstrates the feasibility of implementing an evidence-informed approach to community coalitions in an Army environment.

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July September 2014 83 address public health concerns, there is a strong need to document and evaluate the evidence supporting their effectiveness. 2 Therefore, this study: 1. Describes the need for a CHPC model to coordi nate the Army public health system. 2. Outlines the CHPC model and the evidence that informs its development. 3. Reports the results of initial studies of CHPC effectiveness. 4. Establishes an agenda for future research. TH E NEE D FOR ARMY COMMUNITY HEA LTH PROMOTION COUNCILS Within most public health systems, the various compo nents are typically owned and operated by different or ganizations such as schools, hospitals, and community health departments. Integration among these elements agree on overall objectives, freely share information, and plan and implement complementary activities in the context of an agreed upon overall health response plan. 3 Research shows that effective coordination among stakeholders in public health allows public health sys tems to achieve their mission, address health problems and respond to economic and performance demands. 4 For example, integrating stakeholders within a public health system resulted in a dramatic rise in funding for such as immunizations, malaria, and HIV/AIDS. 5 Conversely, a fragmented approach to public health ing or lack of awareness of the true causes of problems, increased costs, public health errors, and ultimately poorer population health. 6 The Institute of Medicine reports that failures in system capabilities are often a result of how public health services are organized and delivered across communities. 7,8 Systemic errors occur, including poor reporting and communication of popula tion health trends rather than technical failures. 9,10 These acknowledgement of a need for strong and integrated services within public health systems. 11 Research demonstrates that integration within a public health system is largely driven by the extent to which there are clear processes and a strong governing body regulating the interaction of agencies and organizations. Further, effective governance involves bringing constit uents together and facilitating their actions within the system to accomplish system-wide goals. The system should document and disseminate how the various components of a public health system function; provide their constituents with information about the evidence supporting programs, policies, services, and the effec tiveness of other public health practices; and ensure the access of target populations to those services. 12 The information collected through the public health system and its governing body allows the effective allocation of resources, maximizes the collective impact of pub lic health practices within the system, and allows pub lic health stakeholders to methodically identify system strengths and weaknesses. 13 Similarly, Army installations operate with interdisci plinary, complex systems that affect the health and wellbeing of the Army communities. For example, Army in stallations are governed through traditional, functional chains of command. Generally, these functional lines training and development, strategic operations); garri son operations (programs, services, facilities); and med ical operations (healthcare services). The functional ar eas create many unique and overlapping systems within the overall Army public health system. The functional chains of command have the tendency to stovepipe and suring leadership and accountability in achieving spe health issues that require a multidisciplinary approach. An example: suicide is a major, current public health concern in the Army. However, the ability to prevent suicide in the Army is within the purview of multiple commands and Army agencies. The Medical Command (MEDCOM) employs behavioral health providers that treat behavioral health disorders among Soldiers, 14 the Army G1 (the Chief of Staff for Manpower and Human Resources) develops and administers a suicide preven tion program and other programs that affect risk factors associated with suicide, such as the Army Substance Abuse Program, 15 and the Army G3/5/7 (the Director of Strategy, Plans, and Policy) administers Comprehensive Soldier Fitness, a program designed to train Soldiers to become more psychologically resilient. 16,17 These pro grams have complementary missions, but had no formal forum to coordinate their approach to suicide prevention at an installation level. 18 Therefore, Army installation CHPCs evolved to bring representation from different ordinated approaches to public health concerns without reducing the autonomy of existing systems or disturb ing the functional chain of commands in the Army or ganizational structure. In other words, the goal of the

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84 http://www.cs.amedd.army.mil/amedd_journal.aspx CHPC is to build a public health infrastructure and pub motes health and prevents disease within the existing Army organizational structure on an installation. The standard CHPC model, illustrated in Figure 1, is marked by 3 critical features. First, the CHPC is chaired by the highest level of leadership on an Army installation (the installations senior commander). The senior com mander champions and leads the CHPC, and provides environments that affect the health of the installations population. Second, the CHPC is organized and man aged by a health promotion operations team. The health promotion operations team consists of a health promo sistant (HPRA). The health promotion operations team consists of members of the senior commanders full time staff and is responsible for facilitating the CHPC and en suring it is consistent with Army regulations and meets the standards developed by the Army Institute of Public Health of the USAPHC. The health promotion team pro vides subject matter expertise on the public health pro cess to the senior commanders staff and ensures coordi systematic data collection, sets priorities through a health promotion strategic plan, oversees the develop ment and implementation of health promotion programs and policies to address these priorities, and oversees the evaluation of the effectiveness of programs and policies. The third critical feature of the standard CHPC model is centralized management through the USAPHC. The USAPHC is a subordinate command to MEDCOM and oversees the administration of public health in the Army. It also collaborates with other Army oversight agencies such as the US Army Forces Command, US Army Training and Doctrine Command, the Army Ma teriel Command, the Army Installation Management Command, as well as other Army senior leaders such as deputy chiefs of staff of the Army and assistant sec retaries of the Army to address the Armys public health concerns. Through centralized management, HPOs, CHPCs, and senior commanders are able to remove bar ence over programs and policies that are set at higher, strategic levels of the Army. Furthermore, USAPHCs direct oversight of the CHPCs ensures that the CHPCs adhere to an evidence-informed program framework. and health promotion research assistants at Army instal lations that adhere to the standard CHPC model. The HPOS and HPRAs are located at 12 posts across the continental United States: Aberdeen Proving Ground, MD; Fort Bliss, TX; Fort Bragg, NC; Fort Carson, CO; Fort Campbell, KY; Fort Drum, NY; Joint Base Lewis-McChord, WA; Fort Polk, LA; Fort Hood, TX; Fort Irwin, CA; Fort Riley, KS; and Fort Stewart, GA. Fourteen oth er installations in this evaluation have established CHPC processes but do not have a designated health promotion EVID E NC E IN FORMING TH E CHP C MOD E L A ND PROC E SS: COMMUNITY CO A LITIONS The CHPC standard model is rooted in community co alition action theory 19 and other research on effective community health coalitions. A community coalition is an organization of individuals representing diverse organizations, factions or constituencies within the com munity who agree to work together to achieve a common goal. 20(p1) The functions of community coalitions are generally to increase capacity through collaboration, help communi ties build social capital to apply to social and health is sues, and to serve as catalysts for change and movement towards desired outcomes (eg, policy change). 21 The community coalition approach grew out of multiple lines of research. For example, public health research indicates that public health problems are complex and rooted in a societys social and ecological context and should be addressed from multiple directions by mul tiple actors in the community. Therefore, community coalitions aim to create synergy and opportunities for collaboration to address public health problems across multiple sectors. 22 Community coalitions seek to em power communities to advocate for their own health and wellness, which is consistent with research demonstrat ing that a populations health is more likely to improve when the community itself is engaged and invested in the community coalition process. 23 Furthermore, better health in a community is more linked with the commu nity health system characteristics (eg, health behaviors and environmental factors in the community) than the performance of the healthcare system (eg, accessibility of healthcare). 24 Finally, community coalitions that aim to advocate for policy changes are supported by research demonstrating that the most effective strategies to im prove the publics health result from changes in policy. 25 Standard Community Health Promotion Council Model Chaired by the senior commander Organized and managed by the health promotion team Centrally managed by the US Army Public Health Command Figure 1. Three critical features of a standard community health promotion council. MANAGING PUBLIC HEALTH IN THE ARMY THROUGH A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL

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July September 2014 85 Research on community coalitions indicates that co alitions can positively attect health indicators such as lead poisoning, adolescent pregnancy, infant mortality, motor vehicle accidents, and tobacco use. For example, the Community Trails Project (a collaborative partner ship) contributed to a 10% annual reduction in alcohol involved automobile crashes. 26 Also, the Community In tervention Trial for Smoking Cessation contributed to increased quit rates among light to moderate smokers. 27 Additional case studies from 20 community coalitions indicate that they have a strong and positive impact on sources, developing programs, changing policy, increas ing collaboration, increasing community engagement, involvement, and strengthening an organizations health promotion structure. 28 Not all community coalitions are equally effective. 28 Re munity coalitions is affected by multiple factors. For example, a review of 26 studies concerning community coalition effectiveness found that 5 factors predicted community coalition success in at least 5 studies. These factors include formalization of rules and procedures, leadership style, member participation, membership di versity, agency collaboration, and group cohesion. 29 Co alition leadership is a recurring predictor across several reviews. For example, a study of 10 coalitions formed as a part of the America Stop Smoking Intervention Study for Cancer Prevention highlights the importance of good coalition leadership. 30 These case studies revealed that task-focus, good com munication, quality action plans, and dedicated staff time were related to measures of community coalition effectiveness such as membership satisfaction, success ful action plan implementation, and resource mobiliza tion. 30 Other studies suggest that coalition success is fa cilitated by a supportive organizational climate, ability and ability to develop and advocate for primary preven tion resources within the community. 31 Finally, diverse resolution processes, a theory-driven approach to the community coalitions, the ability of coalitions to evalu ate their effectiveness, and dedicated and competent staff all contribute to the success of community coalitions. 21 The 3 critical features of the standard CHPC model ensure that many of the indicators of coalition and public health system effectiveness are present in the Army CHPC model. The Army CHPC model is wellpositioned to have an affect on policy. The senior com mander at an Army installation has the authority to de velop, disseminate, and enforce policies that affect the public health. For example, a senior commander at one Army installation learned that Soldiers were experienc ing adverse effects from polypharmacy (the prescription of 5 or more medications) because providers were not receiving warnings when placing prescriptions through 32 The senior commander used the CHPC to convey this issue to the Army hospital commander who ensured warnings to prevent polypharmacy were added to the system. The Army CHPC model also places a strong emphasis on formalization of rules and policies and can ensure these rules are executed through centralized manage ment. Each standard CHPC is required to execute the health promotion and health promotion research assistants Adherence to informed community coalition model public health system performance community health and wellness, reduced morbidity and mortality A Fit and Ready Force standardization, accountability, and strategic the US Army Public Health Command through alignment with the Army installation senior commander

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86 http://www.cs.amedd.army.mil/amedd_journal.aspx reports of change in public health programs, practices, and policies; annual survey of CHPC effectiveness; re port on adherence to the program framework; annual strategic plan; annual marketing plan; annual working community resource guide; and quarterly program sta liverables to centralized managers at the USAPHC who ensure the installation health promotion team adhere to the program framework and Army Regulation 600-63 1 Another characteristic of effective coalitions, staff dedi cation time and expertise, is the primary reason for the HPO position. The HPOs are hired based on their com petence in Army culture, leadership, and business man agement skills, and are trained to appreciate their public health role in improving community health as they col laborate with local and USAPHC public health profes sionals in areas of surveillance, community health, pro gram planning, implementation, and evaluation. In summary, the standard CHPC model has several of the core components of an effective community coali tion; dedicated staff time and support, formalized rules and procedures, oversight to ensure quality action plans, and power to affect policy and advocate for primary pre vention resources through the senior commander. None theless, there are currently no published studies testing the effectiveness of the standard CHPC model. Because the standard CHPC is becoming a key strategy for pro moting health and preventing disease and injury within Army populations, additional study to evaluate the mod el is critical. In an effort to evaluate the standard CHPC model, USAPHC is establishing a process for evaluating and monitoring the model to ensure quality, satisfaction, study design, participants, and results. The purpose of this study is to test a foundational as sumption of the CHPC effectiveness theory: the 3 fea tures of a standard CHPC modela CHPC chaired by a strong leader, ie, the senior commander; a full time health promotion team dedicated to the process; and centralized management through the USAPHCwill lead to high quality health promotion councils capable of providing a coordinated approach to addressing pub lic health on Army installations. ME THOD The study employed 2 evaluation questions: 1. Do CHPCs with centralized management through the USAPHC, alignment with the Senior Commander, and a Health Promotion Operations Team adhere more closely to the evidence based CHPC program frame work than CHPCs without these 3 features? 2. Do members of standard CHPCs report that par ticipation in the CHPC leads to a well-coordinated ap proach to public health at the installation? tor (CHPC type), 2-level (standard CHPC vs. nonstan dard CHPC) evaluation design with CHPC program adherence as the outcome variable. A past evaluation of retary of Defense for Health Affairs showed that the ef fect of the critical features of the standard CHPC model was moderated by the amount of time a CHPC had been established.* Therefore, the amount of time a CHPC had been operating was included as an additional predictor of program adherence. The study addressed the second question through a sur vey that measured members perceptions that the CHPC led to a more coordinated public health system. Instruments Program adherence was measured through an instru ment called the structure process evaluation tool (SPET). The SPET is a 58-item self-assessment for CHPC leadership (HPOs, centralized HPO managers, and CHPCs) to measure the extent to which the CHPC is meeting the requirements set forward in Army Regula tion 600-63 1 It includes items such as Does the instal lation have a CHPC that meets quarterly? and Does CHPC membership include representatives from each of the following: medical tactical, community, local? Perception of public health coordination is measured through the CHPC Effectiveness Survey. The Effec tiveness Survey is a 20-item assessment administered yearly to CHPC members to assess the extent to which they perceive the CHPC as achieving its objectives and member satisfaction. In this assessment, participants re spond to items regarding member satisfaction such as in general, how would you rate the overall functioning of the HPO position at your installation on a scale from 1 (Strongly Disagree) to 5 (Strongly Agree). However, only 5 of these items are directly relevant to members perceptions that the CHPC is achieving a more coordinated public health system. Therefore, only these items were analyzed to address evaluation ques tion 2. The items include: Internal military document not readily accessible by the general MANAGING PUBLIC HEALTH IN THE ARMY THROUGH A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL

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July September 2014 87 needs/risks. The CHPC uses data to identify community needs/ risks. The CHPC assesses existing resources for overlaps. priorities. The CHPC facilitates relationships and networking between garrison, medical and tactical assets. Participants and Procedure The SPET and Effectiveness Survey are completed an year by all HPOs or a member of the CHPC (for instal lations without the standard CHPC model). The results of the SPET were aggregated across 6 years (2007-2012) and represents responses from 11 installations with the standard CHPC model and 18 installations without the standard CHPC model. There were a total of 83 (N=83) responses to the SPET. The CHPC Effectiveness Sur vey was completed once per year for 6 years (20072012) by the CHPC membership only where there is a standard CHPC model (N=454). This study was reviewed by the US Army Public Health Review Board and all tools and methods were validated as approved methods of public health practice. The study did not require Institutional Review Board ap proval as all methods and data collected were a part of standard public health practice for community health promotion councils in the US Army. RE SULTS 1 Ordinary least squares regression was used to de termine the extent to which the 3 critical features of the CHPC model and time operating positively pre dicted program adherence. The results revealed that both time (F (5,76) =25.02, P <.0001) and the 3 criti cal features of the standard CHPC model (F (1,76) =28.40, P <.0001) independently pre dicted program adherence. Contrary to prior research, however, the relation between ad herence to the standard CHPC model was not moderated by the time that had elapsed since the CHPC began meeting (F (1,76) =0.06, P =.81). 33 These results are displayed in Fig ures 3 and 4. 2 Data from the CHPC Effectiveness Survey were analyzed with descriptive statistics measuring the extent to which members per ceived the standard CHPCs as achieving the goal of integrating the Army installations local public health systems. The survey results indicated that mem bers responded on the positive side of the scale. In other words, members generally agreed that participating in the standard CHPC model is associated with a more coordinated approach to addressing public health at the installation. Figure 5 presents the results of this analysis. COMM E NT These results provide preliminary evidence that the Standard CHPC Model may lead to a more coordinated approach to public health and may assure that CHPCs follow an evidence-informed design. This data supports the standard CHPC Model where the Army senior com mander provides strong leadership; the health promotion team drives the process with expertise and coordination; and centralized management ensures a standardized ap proach to policy and procedure execution is maintained through evidence of delivery. This is consistent with past research demonstrating that community coalitions and public health systems that have strong leadership, ted by year, demonstrating the relationship between the time the CHPC is 2007 2008 2009 2010 2011 2012 1.4 0.8 1.0 1.2 0.6 0.4 0.2 0 Structure Process Scores health promotion council, demonstrating the effect of a senior com mander aligned and centrally managed health promotions opera 0.80 0.77 0.78 0.79 0.76 0.75 0.74 0.73 0.72 Structure Process Scores Nonstandard CHPC Standard CHPC

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88 http://www.cs.amedd.army.mil/amedd_journal.aspx governance and oversight, and formalized rules and reg ulations function more effectively than those without. 3,4 It also demonstrates the feasibility of implementing an evidence-informed approach to community coalitions in an Army environment. The Army model is not only supported by methodologies described in the literature, the evidence from the process validates those same methodologies and contributes to the body of knowl edge on the effect of coalitions on public health process management in communities. LIMIT A TIONS tors. Because the SPET is a self-report and completed by HPOs who are motivated to appear successful in devel oping an effective CHPC, the data from the SPET may be biased. However, this study assumes that participants in the study representing nonstandard CHPCs are also motivated to adhere to the regulations for installations CHPCs. Most likely, this bias is present in both standard and nonstandard CHPCs. At this time, the CHPC effec tiveness survey is only completed at installations with a standard CHPC. Therefore, there is no way to compare whether or not standard CHPCs perform better on this survey than nonstandard CHPCs. AN AG E ND A FOR FUTUR E RE S EA RCH The studies support the link in the effectiveness theory between the 3 critical features of the standard CHPC model and a better coordinated approach to public health. However additional evaluation studies are needed to substantiate the effect of the standard CHPC model on management. Reviews of past research suggest that traditional program evaluation methods are often inadequate to capture the effect of community coalitions on population health. 21 For example, there are only 12 standard CHPCs in the Army. At the community level, there are tential confounders that may cloud the effects of standard CHPCs. Thus, traditional research be underpowered to detect the direct effect of a CHPC on community health and wellness. policy, program, and environmental changes initiated through CHPCs could potentially dem onstrate the positive effects of the standard CHPC on population health and wellness. For example, one CHPC implemented an additional wellness service which was associated with a decrease in Soldiers body mass index and increased help-seeking behaviors.* According to an annual report provided to USAPHC, the CHPCs imple cal year 2012 that aimed to improve community health resources at an installation. Using program evaluation methodologies to assess the impact of these individual initiatives may dramatically increase the evidence to support the effectiveness of the standard CHPC model, as well as provide greater insight into what programs, policies, and environmental changes will effect health promotion and disease prevention in the Army. CONCLUSION The standard Army CHPC model evolved to meet a need for better coordination within the Army public health system and presents a key strategy to achieving better health among Soldiers and their Families, retir ees, and civilians. Based on past research and the stud ies presented here, the standard Army CHPC model is poised to positively affect the Army public health sys tem, community health and wellness, public health re source management, and ultimately military readiness. The potential effect of the Army CHPC model, together with the opportunities it presents for interesting and re vealing evaluation studies, suggest an exciting future for the study of public health management in the Army. 4.06 3.72 3.80 3.99 3.64 Average CHPC Effectiveness Scores The CHPC facilitates relationships and networking between garrison, medical and tactical assets. The CHPC uses data to identify needs. The CHPC identifies gaps in existing resources. The CHPC develops action plans for identified priorities. The CHPC identifies overlaps in existing resources. Internal military document not readily accessible by the general MANAGING PUBLIC HEALTH IN THE ARMY THROUGH A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL

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July September 2014 89 RE F E R E NC E S 1. Army Regulation 600-63: Army Health Promotion Washington, DC: US Dept of the Army; 2007 [re vised 2010]. Available at: http://www.apd.army.mil/ 2. The United States Armys Ready and Resilient Campaign Plan. Aberdeen Proving Ground, MD: US Army Public Health Command; March 1, 2013. Available at: http://usarmy.vo.llnwd.net/e2/c/down loads/285588.pdf. Accessed March 15, 2013. 3. World Health Organization. Humanitarian Health Action: Technical Guidelines in Emergencies; chap 9.1, Facilitating Coordination/Leading a Country Health Cluster. Available at: http://www.who.int/ book/9/en/index1.html. Accessed March 15, 2013. 4. Lasker RD. Medicine and Public Health: The Pow er of Collaboration New York, NY: The New York Academy of Medicine; 1997. Available at: http:// www.uic.edu/sph/prepare/courses/nuph315/re 15, 2013. 5. World Health Organization. Technical Brief No. 1: Making Health Systems Work: Integrated Servic esWhat and Why?. May 2008. Available at: http:// pdf. Accessed March 15, 2013. 6. Holtgrave DR. Public health errors: costing lives, millions at a time. J Public Health Manag Pract 2010;(16):211-215. 7. Institute of Medicine. The Future of Public Health. Available at: http://iom.edu/Reports/1988/TheFuture-of-Public-Health.aspx. Accessed March 27, 2013. 8. berth CD, Ingram RC. Public health performance. Am J Prev Med 2009;(36):266-272. 9. Liu Y. Chinas public health-care system: fac ing the challenges. Bull World Health Organ 2004;82(7):532-538. Accessed March 26, 2011. 10. The World Health Report 2000 Geneva, Switzer land: World Health Organization; 2000. Avail en.pdf?ua=1. Accessed April 28, 2014. 11. Understanding the organization of public health de livery systems: an empirical typology. Milbank Q 2010;88(1):81-111. 12. Halverson PK. Embracing the strength of the pub lic health system: why strong government public J Public Health Manag Pract 2002;8(1):98-100. 13. the curve? What we know and need to learn from public health systems research. J Public Health Manag Pract 2003;9(3):179-182. 14. Army Behavioral Health page. US Army Medical Department web site. Available at: http://www.be havioralhealth.army.mil/. Accessed March 25, 2013. 15. Deputy Chief of Staff Army G-1 page. US Depart ment of the Army web site. Available at: http:// www.armyg1.army.mil/soldiers.asp. Accessed March 25, 2013. 16. Comprehensive Soldier & Family Fitness page. US Department of the Army web site. Available at: http://www.armyg1.army.mil/soldiers.asp. Ac cessed March 27, 2013. 17. sion for psychological resilience in the U.S. Army. Am Psychol. 2011; 66(1):1-3. 18. Army Health Promotion Risk Reduction Suicide Prevention: Report 2010 Washington, DC: US Dept of the Army; 2011. Available at: http://csf2. army.mil/downloads/HP-RR-SPReport2010.pdf. Accessed March 27, 2013. 19. Butterfoss F, Kegler M. The community coali tion action theory. In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Pro motion Practice and Research: Strategies for Im proving Public Health 16th ed. San Francisco, CA: Jossey-Bass; 2009:157. 20. Feighery E, Rogers T. Building and Maintaining Effective Coalitions. How-To Guides on Com munity Health Promotion. Palo Alto, CA: Health Promotion Resource Center, Stanford University School of Medicine; 1990. Available at: http:// pdf. Accessed April 28, 2014. 21. Developing a Conceptual Framework to Assess the Sustainability of Community Coalitions PostFederal Funding. Bethesda, MD: National Opinion Research Center; 2010. Available at: http://aspe.hhs. gov/health/reports/2010/sustainlit/report.shtml. Accessed March 27, 2013. 22. Butterfoss FD, Goodman RM, Wandersman A. Community coalitions for prevention and health promotion. Health Educ Res 1993;8(3):315-330. 23. Giles WH, Holmes-Chavez A, Collins JL. Culti vating healthy communities: the CDC perspective. Health Promot Pract 2009;10(suppl 2):86S87S. 24. Arah OA, Westert GP. Correlates of health and healthcare performance: applying the Canadian Health Indicators Framework at the provincialterritorial level. BMC Health Serv Res 2005;5:76.

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90 http://www.cs.amedd.army.mil/amedd_journal.aspx 25. Ten great public health achievementsUnited States, 2001-2010. MMWR Morb Mortal Wkly Rep 2011;60(19):619-623. Available at: http://www.cdc. gov/mmwr/preview/mmwrhtml/mm6019a5.htm. Accessed April 29, 2014. 26. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000;21:369-402. 27. Fisher EB, Auslander WF, Munro JF, Arfken CL, Brownson RC, Owens NW. Neighborhood for a smoke free north side: evaluation of a community organization approach to promoting smoking ces sation among African Americans. Am J Public Health 1998;88(11):1658-1663. 28. Berkowitz B. Studying the outcomes of commu nity-based coalitions. Am J Community Psychol 2001;29(2):213-227, 229-239. 29. Zakocs RC, Edwards EM. What explains commu nity coalition effectiveness?: A review of the litera ture. AM J Prev Med 2006;30(4):351-361. 30. Kegler MC, Steckler A, Mcleroy K, Malek S. Fac tors that contribute to effective community health promotion coalitions: A study of 10 Project AS SIST coalitions in North Carolina. American Stop Smoking Intervention Study for Cancer Prevention. Health Educ Behav 1998;25(3):338-353. 31. Florin P, Mitchell R, Stevenson J, Klein I. Predict ing intermediate outcomes for prevention coali tions: a developmental perspective. Eval Program Plann 2000;23(3):341-346. 32. Koh Y, Kutty FB, Li SC. Drug-related problems in hospitalized patients on polypharmacy: the in Ther Clin Risk Manag 2005;(1):1033-1036. AUTHORS Ms Courie is a Health Promotion Policy and Operations Promotion and Wellness Portfolio, Health Promotion Operations Program, US Army Public Health Command, Aberdeen Proving Ground, Maryland. Dr Rivera is a Public Health Scientist, Army Institute of Public Health, Health promotion and Wellness Portfolio, Public Health Assessment Program, US Army Public Health Command, Aberdeen Proving Ground, Maryland. Dr Pompey is a Program Evaluator, Army Institute of Public Health, Health promotion and Wellness Portfolio, Public Health Assessment Program, US Army Public Health Command, Aberdeen Proving Ground, Maryland. MANAGING PUBLIC HEALTH IN THE ARMY THROUGH A STANDARD COMMUNITY HEALTH PROMOTION COUNCIL MODEL

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July September 2014 91 In an effort to stay relevant and competitive, companies and organizations explore ways to streamline process es while continuing to deliver quality products and/or services to their customers. Two hallmarks of process improvement are the Lean principle, with its focus on speed, and the Six Sigma principle, with its focus on quality. 1(p15) Combining these principles, Lean Six Sigma (LSS) is a complementary process-improvement, problem-solving methodology used in the business and manufacturing industries to improve the speed, quality, and cost of products. 1(p15) LSS is commonly associated with manufacturing enti ties and corporations such as GE, Motorola, Toyota, and Lockheed Martin. However, over the past decade, the LSS methodology has expanded into other organization al realms. LSS has been used to improve knowledgebased products from service organizations such as hos pitals, 2 3 and research and develop ment organizations. 4 This article presents an example of the use of LSS to improve knowledge-based products in the public health sector. In July 2008, the Army Institute of Public Health Behav ioral and Social Health Outcomes Program (BSHOP) was established at US Army Public Health Command. The mission of BSHOP is to maximize total Soldier health and combat readiness by identifying and assessing the relative impact of psychological and social threats using a mixed methodological approach. At inception, one of the primary missions of BSHOP involved routine report ing and surveillance of suicidal behavior among Soldiers using data from the Army Behavioral Health Integrated Data Environment (ABHIDE). The ABHIDE is one of the most comprehensive data sources for suicidal behavior and includes data from 27 disparate administrative data sources. The BSHOP created the Surveillance of Suicidal Behavior Publication (SSBP), which is disseminated to key military leaders including the Vice Chief of Staff of the Army, the Army Surgeon General, public health practitioners, and behavioral health providers at regional medical commands and military treatment facilities. As the mission and scope of BSHOP expanded, it be came apparent that preparation of the SSBP was a timeand resource-intensive process that prevented epidemi ologists and analysts from exploring other behavioral the process allows consistency in methods and provides Performance Excellence: Using Lean Six Sigma Tools to Improve the US Army Behavioral Health Surveillance Process, Boost Team Morale, and Maximize Value to Customers and Stakeholders Eren Youmans Watkins, PhD, MPH John V. Wills, BS Dave M. Kemeter, MBB Brent Edward Mancha, PhD, MHS Anita Spiess, MSPH Jerrica Nichols, MPH Elizabeth Corrigan, MS Amy Millikan Bell, MD, MPH Keri Kateley ABSTR A CT Lean Six Sigma (LSS) is a process improvement, problem-solving methodology used in business and manufacturing to improve the speed, quality, and cost of products. LSS can also be used to improve knowledge-based products in tegral to public health surveillance. An LSS project by the Behavioral Social Health Outcomes Program of the Army Institute of Public Health reduced the number of labor hours spent producing the routine surveillance of suicidal behavior publication. At baseline, the total number of labor hours was 448; after project completion, total labor hours were 199. Based on customer feedback, publication production was reduced from quarterly to annually. Process improvements enhanced group morale and established best practices in the form of standard operating procedures and business rules to ensure solutions are sustained. LSS project participation also fostered a change in the concep tualization of tasks and projects. These results demonstrate that LSS can be used to inform the public health process and should be considered a viable method of improving knowledge-based products and processes.

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92 http://www.cs.amedd.army.mil/amedd_journal.aspx time to explore not only other negative outcomes im portant to public health, but also to expand what can be included in the SSBP. This article describes an LSS proj ect completed by the BSHOP Behavioral Health Surveil lance Section (BHSS). Unlike other publications related to process improvement, 5 this article describes how an industry tool was used to enhance a public health sur veillance process for the US Army. ME THODS Measure-Analyze-Improve-Control (DMAIC). Using the problem they wish to solve, identify the true cause of the problem, develop solutions based upon data, and establish procedures for maintaining the solutions. 1(p57) Before initiation, the LSS team created a project charter, a 1to 2-page iterative document that includes the prob lem and goal statement, a timeline, and a list of the LSS team members. The charter was updated as the project developed through each of the DMAIC phases. The DMAIC methodology and associated tools are dis cussed in detail by George et al. 6 A brief description of each phase as it pertains to the SSBP project is present ed in the following sections. Define The LSS team and the Project Sponsor (the BSHOP Pro set up a communication plan. The team created a highlevel (overview) map of the process and established the project scope (Figure 1). The project process begins when the team receives the data to begin producing the SSBP and ends when the BSHOP Program Manager ap proves the publication. Next, the team created a detailed map of the process, describing each team members position and the tasks associated with each section of the publication. In doing proved their understanding of each team members role and responsibilities. Like the project charter, the process map is an iterative document and was updated through Measure During this phase, the LSS team used baseline data and determined process performance/capability using Sig ma Quality Level (SQL), a measure of process perfor mance with respect to meeting customer requirements. A 3 SQL process meets customer requirements 93.3% (yield) of the time; a 6 SQL process meets customer re quirements 99.9% of the time. 3(p25) The team also developed a data collection plan to assist in the Measure phase. As part of this plan, team mem bers recorded the number of hours they spent on each section of the publication. At the end of each publication cycle, a data technician compiled the information and created a table summarizing completion time by task were also created to ensure clarity and consistent in terpretation for each task. For example, New Code was has not been included in previous reports. Data analyst writes code to pull the same values in Structured Query Language to validate SAS code. (SAS v9.2 software (SAS Institute Inc, Cary, North Carolina) was used for based on a fully burdened labor rate (base rate +34.1% Analyze During the Analyze phase, the LSS team analyzed the data collected during the Measure phase. A Pareto chart was used to specify the process steps that required the most labor hours and the most common source of de fects. A Cause & Effect (C&E) Diagram, shown in Fig ure 2, and Matrix helped the team organize ideas and determine which critical factor(s) were increasing the number of hours required to produce the SSBP. Using prioritized 3 root causes that had the most effect on pub lication production hours. PERFORMANCE EXCELLENCE: USING LEAN SIX SIGMA TOOLS TO IMPROVE THE US ARMYS BEHAVIORAL HEALTH SURVEILLANCE PROCESS, BOOST TEAM MORALE, AND MAXIMIZE VALUE TO CUSTOMERS AND STAKEHOLDERS Figure 1. High level (overview) process map of the Lean Six Sigma project to enhance a public health surveillance process for the US Army Public Health Command. START Receive Data BSHOP Program Manager Approval END Submit to BSHOP Program Manager Prepare SAS Code Perform Analysis Edit Text Internal Peer Revisions Create Tables and/or Graphs

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July September 2014 93 Improve The Improve phase involved changes in the process that would reduce the number of labor hours spent producing the publication. Based upon the information obtained during the Analyze phase, the team conducted a pilot as sessment to test their proposed improvement. The goal of the pilot was to demonstrate that changes in the criti number of hours in the process while simultaneously maintaining the quality and integrity of the SSBP. Team members also developed potential solutions to other pri oritized causes by brainstorming ideas, then evaluated those solutions using agreed-upon criteria. Control The Control phase ensured that solutions would be maintained after LSS project completion. To that end, the LSS team documented the solutions. A process con trol plan was created and the new and improved process performance and capability were compared to the old RE SULTS Baseline Four data points (previous SSBPs) were used to deter mine the average number of hours spent to complete a single publication (baseline). The LSS team and spon sor recognized that a larger sample size would be ideal. However, given that the section produces surveillance publications for a rare event (suicidal behavior), 4 data erage, each of the previous publications took 448 (95% exceeded the expected standard of 308 hours which was established based on comparison with the time another organization takes to produce a similar document. At baseline, the process was stable over time (in sta tistical control). However, process SQL was less than one. This indicated that the process was not capable of consistently producing the SSBP within the determined Using a Pareto chart, the team determined that pre paring SAS code and running statistical analyses ac counted for 75% of the labor hours. Based on analysis root causes that needed solutions: (1) lack of personnel, (2) lack of analytic datasets and methodology, and (3) lack of standardization in SAS coding. The team agreed that focusing efforts on the SAS coding process would have the greatest effect on reducing the number of labor hours. Therefore, this part of the process was used as the pilot for the Improve phase. For the pilot, SAS and Structured Query Language labor hours for the 1st Quarter 2012 Surveillance of Suicidal Behavior Update and the 2012 Semiannual SSBP were used as the before period, while SAS and Structured Average number of labor hours to produce a report Figure 2. Cause and effect diagram used to organize ideas and determine which critical fators were increasing the number of hours required to produce the publication. Lack of analytic data set(s) No detailed schedule Inconsistent denominator data Inconsistent denominator data forcing recalculation of rates Proper training No standard code No standard format No standard content Small number of staff Difficult to replicate Difficult to use Competing priorities (RFIs, Taskers) Number of full reports to be produced Number of full reports to be produced Awkward and unappealing report design Absence of specific task assignments among staff Lack of outside statistical tool to check coding Lack of outside statistical tool to check coding Review of formatting text added time to incorporation of edits Lack of documented standard operating procedures Reran data each time information was updated in the ABHIDE Need to verify data to be eliminated Data errors necessitate many checks and rechecks Data Errors Manpower Standardization Product Administrative Method 3 2 1 indicates a critical X

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94 http://www.cs.amedd.army.mil/amedd_journal.aspx Query Language labor hours for the 3rd Quarter 2012 Update and the 2012 Annual SSBP were used as the the team spent 223 hours on SAS coding and Structured period and 90 hours in the after period. Notably, the majority of the time in the after period was spent on code for new analyses not included in previous publica tions. The reduction in hours (178) during the pilot as sessment demonstrated that SAS coding and Structured in SSBP production hours. Final Improvements in labor hours ( yield (+89.4%) and SQL (+3.25) as shown in the Table. The projected 7-year cost avoidance for US Army Pub lic Health Command was $707,045. Control measures were implemented to ensure improvements would be maintained after project completion. The team created 8 documents. Chief among these is the Technical Notes, which describe, in detail, epidemiologic methodolo gies (data sources, variables, coding decisions) used for SSBP production. The Technical Notes are updated with each iteration of the SSBP. COMM E NT cantly reduced the SSBP production hours by 42% (199 hours). The results of this project are important because, to our knowledge, this is one of only a few LSS projects that applied this industry tool to the improvement of a public health surveillance system. These results dem onstrate that LSS can inform the public health process and provides a viable method of improving knowledgebased processes and products. As determined during the Analyze phase, SAS coding for the majority of the time during the production pro ing and analysis were consistent and correct. When the SAS code became standardized and error-free, the LSS team determined this practice no longer added value. for new SAS code. When discrepancies have been ad dressed and accounted for, that step is removed from the production process. As a result of the LSS process, the team maintained the quality of the SSBP and reduced production time, while at the same time adding valuable information. This in cluded measures from 4 datasets in the ABHIDE per taining to deployment, drug testing, screening for the Army Substance Abuse Program, and medical problems related to sleep and to pain. These indicators are now routinely included in the SSBP. In addition to revising and standardizing SAS coding, better align with the overall process of analysis and re production. Prior to the redesign, project team members were rewriting the entire document every quarter. The new design is not only aesthetically pleasing and more appealing to the customer, it also allows easy duplication and transfer of the data from SAS outputs to the table and text. To maintain consistency, the team developed a detailed SOP describing all aspects of document design The development of business rules also led to gains in consistency in epidemiologic methodologies and analyt ulation Data Sources (US Census Data and Web-based the following: (1) use of Health Care Effectiveness Data and Information Set rules to determine what constitutes a behavioral health diagnosis; (2) internal review of be havioral health diagnoses and their International Clas Strategic and Clinical Integration and Evaluation Sec tion) and external review by clinicians (colleagues and subject matter experts); (3) alignment of race/ethnic guidelines; (4) creation of a process to resolve discrep ancies in static demographic variables (gender, date of birth, race/ethnicity). The team also created a welcome packet that is used as a training tool to systematically in troduce new personnel to section processes and products. The LSS team developed and distributed a stakeholder SSBP feedback survey. Based on team discussion of feedback from the survey, the SSBP is now released PERFORMANCE EXCELLENCE: USING LEAN SIX SIGMA TOOLS TO IMPROVE THE US ARMYS BEHAVIORAL HEALTH SURVEILLANCE PROCESS, BOOST TEAM MORALE, AND MAXIMIZE VALUE TO CUSTOMERS AND STAKEHOLDERS Process improvements realized as a result of the Lean Six Sigma project Metric Before After +/Reduced number of Labor Hours 448 199 -249 Increased Sigma Quality Level <0 3.25 +3.25 Increased Yield <6.6% 96% +89.4%

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July September 2014 95 annually rather than quarterly. Data on cases of suicid each calendar year are analyzed but disseminated only if cy of reporting also enhanced interpretation of the data. In particular, the variability in the proportions from quarter to quarter resulting from the small numbers of suicidal events suggested changes that appear large but are unimportant in the context of a longer period. In addition to the successes described above, the team realized substantial gains in team building and enhanced workplace morale. Project participation turned LSS skeptics into champions of the process and fundamen tally changed the way team members conceptualized tasks and projects. As a whole, individuals now think in terms of process improvement. Statements such as from an LSS perspective we should or is this the most ef now commonplace in the work environment. The in volvement of BHSS in the project also piqued interest in LSS tools and methodologies among other sections with in BSHOP and resulted in 15 employees obtaining their in cross-section collaboration, and the sharing of ideas has aided in the scholastic enrichment of individuals and teams. Support from the BSHOP Program Manager and excellent mentorship and guidance from the LSS expert also integral to the success of the project. CONCLUSION There are 3 reasons why service-oriented organizations should consider LSS tools and methodologies when try ing to improve a process, all stemming from the fact that service processes are typically slow. 3 First, slow process es are subject to poor quality, which increases cost and drives down customer satisfaction. 3 Second, service pro cesses are often slow because too much work is in prog ress, which results in unnecessary complexity in the ser vice or product. 3 Third, in any slow process, 80% of the delay is caused by less than 20% of the activities. 3 Indi most of the steps in the process add no value to the prod uct they are producing. Use of LSS to identify and quanti fy the steps in the process that are not of value will result in improvements 3 as demonstrated by the BSHOP LSS project described here. The time and knowledge gained from this project have enabled the exploration of other those added to the SSBP during the course of the proj ect. In addition, the team has begun applying LSS tools and methodologies to other surveillance publications, including those on all-cause mortality in the US Army, risk assessment, and sexual assault. Other programs and the US Army Medical Command, could use LSS tools to improve relatively simple (organization and structure of public access drives, version control for document review intake process or routine medical procedures) in need of determine feasibility of a proposed project. ACKNOWL E DGM E NTS The project was supported in part by an appointment to the for Health Command (USAPHC) administered by The Oak ment between the US Department of Energy and the US APHC. We thank the following individuals for their support and/or contribution to this work: Christopher Watts, MPH; APHC; Dr Bradley Nindl, Science Advisor, Army Institute of Health; MG Dean Sienko, Commander, USAPHC. RE F E R E NC E S 1. What is Lean Six Sigma? New York, NY: McGraw-Hill; 2004. 2. Feng Q, Manuel CM. Under the knife: a national survey of six sigma programs in US healthcare organizations. Int J Health Care Qual Assur 2008;21(6):535-547. 3. George M. Lean Six Sigma for Service New York, NY: McGraw-Hill; 2003. 4. Schweikhart SA, Dembe AE. The applicabil ity of Lean and Six Sigma techniques to clinical and translational research. J Investig Med 2009; 57(7):748-755. 5. turnover in transactional services: a Lean Six Sigma case study. Int J Prod Perform Manag 2010; 59 (7):688-700. 6. The Lean Six Sigma Pocket Toolbox New York, NY: McGraw-Hill; 2004. AUTHORS Dr Watkins, Ms Spiess, Mr Wills, Dr Mancha, Ms Nichols, and Dr Bell are with the Behavioral and Social Health Outcomes Program, Army Institute of Public Health, US Army Public Health Command, Aberdeen Proving Ground, Maryland. US Army Public Health Command, Aberdeen Proving Ground, Maryland. Ms Corrigan and Ms Kately are with the Batelle Eastern Science and Technology Center, Aberdeen, Maryland.

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SUBMISSION OF MANUSCRIPTS TO THE ARMY MEDICAL DEPARTMENT JOURNAL The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewe d print medium to encourage dialogue concerni ng health care issues and initiatives. REVIEW POLICY All manuscripts will be reviewed by the AMEDD Journal Â’s Editorial Review Board and, if re quired, forwarded to the appropriate subject matter expert for further review and assessment. IDENTIFICATION OF POTENTIAL CONFLICTS OF INTEREST 1. Related to individual authorsÂ’ commitments: Each author is responsible for the full disclosure of all financial and personal relationships that might bias the work or information presented in the manuscript. 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