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.

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Digital Military Collection

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January March 2015 Perspective 1 MG Steve Jones US Army Public Health: One Health, One Medicine, One Team 3 LTC Ronald L. Burke; COL Casmere H. Taylor Agroterrorism: The Risks to the United States Food Supply and National Security 9 SFC Kevin M. Gill Evaluation of the US Army Institute of Public Health Destination 16 Monitoring Program, A Food Safety Surveillance Program MAJ Kamala Rapp-Santos; Karyn Havas, DVM, PhD; Kelly Vest, DVM, DrPH, MPH Environmental Requirements Related to Patient Care and the Team 25 Working to Ensure Compliance Diane Roberts Preventive Medicine Oversight of Splash Pads on Military Installations 32 Lisa Raysby Hardcastle, PE; MAJ Matthew Perry; CPT Ashley Browne Fluoridating Army Community Water Systems in the US Army 38 Public Health Command Region-West Area of Responsibility Lisa Raysby Hardcastle, PE; CPT Ashley Browne; 1 LT Charles Pham Tick-borne Disease Surveillance 49 MAJ Wade H. Petersen; CPT Erik Foster; 1 LT Beven McWilliams; William Irwin Managing Your Differential Diagnosis List: Considering Bias and Recognizing 56 Unexpected Infectious Agents CPT Lauren Seal; CPT Aimee Hunter Fielding the Remote Online Veterinary Record, a Veterinary Electronic Health 61 Record to Improve Patient Care and Practice Management CPT Meghan C. Nelson; LTC Ronald L. Burke Joint Base Lewis-McChord First Year Graduate Veterinary Education: 67 Observations and Lessons Learned CPT Aimee Hunter; CPT Teresa Villers; CPT Lauren Seal; David Galloway, DVM ALSO IN THIS ISSUE Associations Between Operationally Estimated Blast Exposures and Postdeployment 73 Diagnoses of Postconcussion Syndrome and Posttraumatic Stress Disorder MAJ Jonathan L. Saxe; Christopher L. Perdue, MD, MPH Temperament Dimensions and Posttraumatic Stress Symptoms in a Previously 79 Deployed Military Sample LTC Sandra M. Escolas; Hollie D. Escolas, BA Predicting Willingness to Report Behavioral Health Problems and Seek Treatment 86 Among US Male Soldiers Deployed to Afghanistan: A Retrospective Evaluation LTC Ronald J. Whalen A Heart Gripping Case: Carcinoid Heart Disease 93 Capt John P. Magulick, Maj Frederick L. Flynt, & LtCol Kevin E. Steel (USAF); LTC Nathan M. Shumway Abstracts and Winning Posters Presented at the Graduate School 4th Annual Research Day, 97 Academy of Health Sciences, US Army Medical Department Center & School THE ONE HEALTH CONCEPT IN MILITARY PUBLIC HEALTH

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January – March 2015 The Army Medical Depa rtment Center & Sc hool PB 8-15-1/2/3 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 3630 Stanley RD STE B0204, JBSA Fort Sam Houston, TX 78234-6100. 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 1432501 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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October December 2014 1 Perspectives COMMANDERS INTRODUCTION MG Steve Jones Public health is a discipline concerned with protecting and improving the health of entire populations. Those populations may be a community, a nation, or a military force. Public health is practiced through recommenda tion of policies to elected leaders, administration of ser vices, educational programs, promotion of healthy life styles, and research. Major focus areas for public health are prevention of disease and injury and the detection and control of infectious diseases. The Army Medical Department is responsible for protecting and improv ing the health of the Army, families and retirees. While advances in the science of public health. In April 1776, Dr John Morgan, Director General of the Hospitals and Physician in Chief to the American Army, recommended inoculation of the Continental Army against smallpox. Hundreds of Soldiers died from the disease which was a major factor in the failure in the Quebec Campaign, and fear of the disease discouraged recruiting. With implementation of the inoculation pro 1900, under the leadership of MAJ Walter Reed, the US Army Yellow Fever Commission established the mos quito as the vector for transmission of yellow fever. A control program implemented by MAJ William Craw ford Gorgas effectively reduced the incidence of yel low fever and malaria in Cuba, and a similar program he later implemented in Panama allowed the Corps of Engineers to construct the Panama Canal. 1LT Bailey K. Ashford studied the severe anemia common in Puer to Rico and determined it was caused by infestation of the hookworm Ancylostoma. His work led to a world wide campaign by the Rockefeller Foundation to control hookworm disease. MAJ Carl R. Darnall developed a system for the chlorination of drinking water supplies by treatment with anhydrous chlorine gas. 1 World War II brought the discipline of public health to military government and civil affairs. Army leaders understood that disease in civilians could impede mili tary operations, that public health is an integral part of government (including military government), and that providing medical care for civilians under their control could establish good will and cooperation of the civil population. 2 The current campaign in Afghanistan demonstrates how the role of public health in military operations has evolved. Today the Army provides foundational capa bilities to a team that includes US governmental agen years of drought produced major health problems. The physical infrastructure and human resource base had severely deteriorated, resulting in a health status that was the worst in Asia and among the worst in the world. disabled from war-related injuries, birth complications and weak preventive healthcare services. Each year, of those deaths were preventable, the result of diarrhea, respiratory infections, measles and pneumonia. After the collapse of the Taliban in the fall of 2001, the World Bank, Asian Development Bank, and United Nations Development Programme conducted an assessment of reconstruction requirements. They determined a major need was the development of a basic healthcare system to provide preventive and public health services. Imple mentation of a few vital but low-cost programs would of communicable diseases, maternal newborn and child health, nutrition supplementation, treatment of mine and war related injuries, and promotion of a healthy lifestyle. The US Agency for International Development led the reconstruction effort and Coalition forces played a sup es, dramatic improvements were achieved and today life expectancy has increased from 42 to over 62 years, ma The global security environment is continuously be coming more complex and volatile, and the Army must prepare for the rapid emergence of new and increas THE US ARMY A ND PU BLIC HE A L T H

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2 http://www.cs.amedd.army.mil/amedd_journal.aspx should plan. 6 Several scenarios he discussed present Army, such as the possibility of war on the Korean peninsula. For example, as more capable South Korean forces advanced, an always unpredictable and histori cally unstable North Korean regime could use a nuclear ening to use another against Seoul. In this admittedly area where nuclear weapons had been employed, while responding to the accompanying civilian humanitarian disaster. past. This is partly due to the emergence of megacities with populations of 10 million or more. For example, a nuclear reactor meltdown near a megacity such as Ka rachi could affect 20 to 30 million people, and require a response far greater than that required after the 2011 disaster at Fukushima, Japan. Many large cities lack ef fective governance, basic infrastructure, public health services, and communication systems which would West Africa. In view of the instability that is endemic across the continent, it is not implausible that one day we may be contending with Ebola in the midst of a civil war. In that environment, the Army could be assigned the mission of both cordoning off an area of infection and administering health care. The public health chal lenges of such a mission would be immense. Public health has been an important mission of the Army Medical Department since its establishment humanitarian crises at home and abroad, and made of billions of people around the world. As the Army Force 2025 and Beyond Army Medicine will maintain its focus on this important mission. REFERENCES 1. Baynes-Jones S. The Evolution of Preventive Medi cine in the United States Army, 1607-1939 Wash 2. Baynes-Jones S, Church WD, Dehne EJ, et al. Civil Preven tive Medicine in World War II 3. Asian Development Bank, United Nations Develop ment Programme, World Bank Preliminary Needs Assessment Team. Afghanistan, Preliminary Needs Assessment for Recovery and Reconstruction Jan 4. Health in Afghanistan Situation Analysis US Agency for International Development. US AID Fact Sheet, USAID Engagement in Afghani stan 2014 and Beyond [internet]. February 2014. 6. saries and future Army missions. Paper presented burg, Virginia. PERSPECTIVES

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January March 2015 3 One Health is the concept for bringing together health promotion and delivery for humans, animals, and the environment (Figure 1). 1 The One Health concept rec ognizes that success in one profession such as human health often requires coordination with the other two. Failure to account for these relationships can have disas trous consequences. Vector-borne disease control is an example of how the 3 disciplines are related. Over one million people die each year from diseases such as malaria, dengue, and yel low fever, which are transmitted by mosquito vectors. 2 solution to vector-borne diseases. It was inexpensive and persistent, and over the next few decades, DDT was widely used throughout the world with great success at reducing mosquitoes. For example, the Aedes aegyp tii mosquito was eradicated from dozens of countries within the western hemisphere, which in turn led to sig vector control programs were so successful that some people soon began asserting that these diseases would be wiped out and no longer threaten the human race. Unfortunately, these assertions failed to recognize the negative impacts of DDT on the environment and ani mals. Bioaccumulation within the environment (a result of DDTs persistence) was linked to eggshell thinning and decreased reproduction rates in birds of prey. 3 Con cern was also voiced that the birds were biosentinels and an early warning to potential human risks, which is sup ported by recent studies suggestive of possible adverse effects in humans. 4 The negative animal and environmental effects of DDT eventually led to use restrictions and bans in the United States and many other countries. The bans in turn have been criticized as harmful to humans by increasing ex posure to vector-borne diseases leading to increased mortality. 5 These criticisms may be partially responsible for the recent resurgence of DDT use. However, whereas est change in DDT usage (as well as other pesticides) was the shift from widespread agricultural application to targeted indoor residual spraying. Indoor residual spraying takes advantage of the persistent tendencies of DDT to provide inexpensive protection against Anoph eles species and other indoor feeding mosquitoes which transmit diseases, 6 while at the same time avoiding bio accumulation in lakes, streams, and soils that harm the environment, animals, and humans. Used appropriately, such as treating bed nets and rotating insecticides to re duce resistance, indoor residual spraying saves human lives while protecting animal and environmental health. The One Health Initiative recognizes the importance of an interdisciplinary medical team and is dedicated to improving the lives of all specieshuman and ani malthrough the integration of human medicine, vet erinary medicine and environmental science. 7 The One Health Initiative is supported by numerous organiza tions including the American Medical Association, the American Veterinary Medical Association, and the Na tional Environmental Health Association. Multiple US government agencies, including the Centers for Disease riculture, and the Food and Drug Administration, have recognized the importance of One Health and are work ing together to improve health promotion cooperation across the 3 health disciplines. initiative seeks to improve human health through ani mal health. 8 often considered part of the family. Americans spend countless hours each day walking, grooming, and play the cat or dog. This close contact facilitates transmis sion of bacterial, parasitic, and viral infections such as plague, scabies, and rabies. Ensuring pets are healthy and disease free protects human health. Of course, the reverse is also true; healthy people promote healthy pets as diseases can be transmitted from people to pets (zooanthroponosis). US Army Public Health: One Health, One Medicine, One Team LTC Ronald L. Burke, VC, USA COL Casmere H. Taylor, MS, USA

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4 http://www.cs.amedd.army.mil/amedd_journal.aspx and cholesterol and triglyceride levels, and increase op portunities for exercise and socialization. 11,12 An owners desire to keep the pets healthy can impact their own be havior. Although obesity is not infectious, canine and feline obesity is associated with owner obesity. While some owners may be unconcerned or unwilling to ad dress their own health, they may be motivated to im prove the health of their beloved pets, even if it means making personal changes. Addressing canine obesity in particular is a potential method of improving human health, as exercise (walks, runs or playing in the park) dressing canine nutrition requirements may encourage the owner to examine their own eating habits. US ARMY PU BLIC HE A LT H COMM A ND REGION WE S T: PU TTING ONE HE A LT H INTO PR A CTICE The One Health initiative is also being implemented within the US military, particularly within the US Army with the mission to promote health and prevent disease, injury, and disability of Soldiers and military retirees, their Families, and Department of the Army civilian em ployees; and assure effective execution of full spectrum veterinary service for Army and Department of Defense Veterinary missions. 13,14 insignia includes the One Health triangle representing the triad of human, animal, and environmental health, as well as the motto Una Sanitas, Latin for One Health is entitled One Health, further evidence of the organi zations commitment to the concept. sight for its broad One Health mission through portfolio management. Functional specialties such as environ mental health engineering, epidemiology and disease surveillance, health promotion and wellness, and veteri nary services are managed within the Army Institute of US ARMY PUBLIC HEALTH ONE HEALTH, ONE MEDICINE, ONE TEAM Figure 1 Pictorial representation demonstrating how human, animal, and environmental health are related under the One Health umbrella concept. Illustration courtesy of One Health Initiative, reprinted with permission.

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January March 2015 5 and resources are coordinated effectively. Command and control is subordinated through 5 regional com are aligned with the regional medical commands (Fig structure, functions, and missions are the same at the plinary unit with Soldiers and civilians from each of the One Health professions (human, animal, and environ ment). The disciplines are assigned to divisions, which are aligned with the technical portfolios at the Army allows for communication and coordination of efforts at all levels. history of coordinating interdisciplin ary health efforts is the human-envi ronment interface. The World Health Organization estimates that environ total disease burden worldwide. 15 The environment is associated with com municable and infectious diseases, such as the previously discussed vectorborne diseases, but also noncommu nicable diseases such as cancers, re spiratory illnesses, and cardiovascular issues. 16 While these environmental hazards can occur naturally, they can just as easily be man-made. In other words, unhealthy human actions lead to unhealthy environments, which in turn lead to unhealthy humansOne Health at its worst. In recognition of the environment-human health connec towards both detecting environmental hazards and preventing them. An important tool for identifying en vironmental health hazards is the De fense Occupational and Environmental Health Readiness System (DOEHRS). It is a centralized system for storing and managing occupational and en vironmental health hazard (biological, physical, chemi cal) data.* Of course, DOERHS is only as good as the samples that are collected and the data which are en the ability to conduct environmental surveillance and enter the data, they cannot be at every Army installa tion, including those in deployed environments. Instead, icine units on how to conduct environmental surveil lance and enter the data into DOEHRS. Over the past dozen garrison and deploying preventive medicine units Army, Navy, and Marine units have received training on environmental sample collection and data entry. The result is that deployed commanders are given accurate risk assessments for exposed personnel on the ground and recommendations to mitigate health risks, such as the elimination of burn pits. The DOERHS data reposi tory can also be accessed by medical professionals for man health concerns resulting from po tential environmental exposures during past deployments. More recently, the formation of US laborations. For example, the merging of Army preventive medicine and vet erinary medical assets into a single or ganization has strengthened food and water safety at Army installations. Tra ditionally, Army veterinary personnel have been responsible for auditing com mercial food and water suppliers and inspecting deliveries through receipt to ensure the subsistence is safe and wholesome. Inspection of food storage, preparation, and serving, as well as ensuring the safety of installation wa ter treatment facilities, is performed by preventive medicine personnel. While these groups have worked well together, there was the potential for information loss during the handover of responsi bility. Bringing expertise from both groups together under a single organi zation improves coordination, assists problems, and fosters cooperation to develop improved food safety product and measures. One example of this improved collaboration was evident ment of Defense (DoD) Tri-Service Food Code 17 Vector-borne disease surveillance is another aspect The Army, as well as the other military services, Restricted access: https://doehrswww.apgea.army.mil/doehrs dr/index.jsp Figure 2. US Army Public Health Command Distinctive Unit Insig nia. Each side of the triangle rep resents a component of the OneHealth triad: people, animals, and the environment. The shield represents the mission of protect ing the Army family. The green and maroon represent the past and current colors associated with the Medical Corps, respectively. The spear tip represents the organi zations leading role in promoting Soldier health. Medicine and heal ing are represented by the twin serpents around the spear. The unit motto is Una Sanitas, Latin for One Health.

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx collects and tests arthropod vectors for pathogens such as Babesia canis, Borrelia burgdorferi, and Rickettsia parkeri, the causative agents for babesiosis, Lyme dis ease, and tidewater fever, respectively. The arthropods are generally submitted by clinicians following removal from patients or collected as part of environmental sur veillance such as tick drags. These surveillance efforts capture 2 of the 3 populations (humans and environ ment), but they miss the local animal population. Ticks can bite and feed from dogs and cats as easily as hu mans, especially if pets are not treated with an acaricide, which can lead to infection and diseased pets. One of surveillance is through coordination of the environmen tal health, laboratory sciences, and veterinary services divisions to collect, identify, and test ticks collected at installation veterinary clinics throughout the Region. prophylactically treated for infection, but also helps to better quantify the disease transmission risk to other animals, as well as their owners, which in turn shapes future risk mitigation strategies and communications at the installation. The information is also transmitted through the technical portfolio channels and analyzed in conjunction with other surveillance efforts (report able medical events, for example) to prepare products like the monthly Army Vector-borne Disease Report, 18 subscription. The monthly report provides a quick snap shot of vector-borne disease activity within the United States as a whole, within the Army active duty and ben veillance. Eventually, the vector-borne information may be combined with information from veterinary treat Veterinary Record (ROVR) to further quantify the risk of vector-borne disease transmission at Army installa tions. The ROVR is the DoD electronic animal health record system for both government and privately-owned animals and can be queried to identify disease trends and outbreaks. FU T U RE DIRECTION S improve Soldier and family readiness through market ing and leveraging of public health in support of larg er Army and DoD programs. For example, the DoDs Healthy Base Initiative seeks to improve the health and wellness of service members, families, and civilians through better nutrition. Several DoD installations have recently implemented local farmers markets to improve service members eating habits by providing healthy al ternatives to the traditional fast food options on military US ARMY PUBLIC HEALTH ONE HEALTH, ONE MEDICINE, ONE TEAM http://phc.amedd.army.mil Figure 3 Geographic Information Systems Branch (July 2014 ).

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January March 2015 7 installations. However, while these farmers markets may have more nutritious fruits and vegetables in com parison to a burger and extra-large fries, there are health Listeria monocytogenes cases in 28 states, for evidence that even fresh fruits and vegetables can be linked to infectious disease transmis sion. developing food sanitation guidance material for con sumers and food surveillance inspection programs for farmers markets to ensure food safety supports healthy eating behaviors. One Health activities also support The Army Surgeon sees Army Wellness Centers, which provide individual nutrition, stress management, tobacco cessation, and general wellness to assist individuals in developing and reaching their health goals. 21 The program engages in dividuals in their lifespace, their environment, to help them make lifestyle changes, which improve shortand long-term health. These health promotion efforts also extend beyond Army Wellness Centers into all aspects clinic is not a traditional setting for discussing human obesity, yet as previously mentioned, pet owners may be willing to make lifestyle changes for their pets health that they would not make for their own health. These lifestyle changes are not limited to just nutrition either. Dog runs/walks are an excellent way to encourage own er and pet exercise and multiple veterinary clinics are partnering with their local medical treatment facilities or morale, welfare, and recreation activities to organize and promote these events. Looking towards the future, the One Health concept will remain a fundamental element of public health. While Medical Department reorganization, the public health duty will remain a key component mission of the unit, its successor, and the Army Medical Department. As the world becomes more populated and increasingly in terconnected, the interactions between human, animals, and the environment will only increase. The recent in troduction of the Chikungunya virus into the western hemisphere and the ongoing outbreak of Ebola in west ern Africa are 2 examples of outbreaks which are reshap ing our thinking. We cannot assume that the way things were will be the way things are in the future. Effectively preparing for and addressing these future health threats linked and lasting success cannot be achieved unless the medical professions work togetherOne Health, One Medicine, One Team. RE F ERENCE S 1. King LJ, Anderson LR, Blackmore CG, et al. Ex ecutive summary of the AVMA One Health Ini tiative Task Force report. J Am Vet Med Assoc 2. World Health Organization. The Health and Envi 3. A Review to Ban Its Use as a Pesticide aspects-decision-ban-its-use-pesticide. Accessed 4. bis(4-chlorophenyl)-1,1,1-trichloroethane (DDT). Lancet 5. Nation al Geographic 6. Walker K. Cost-comparison of DDT and alterna tive insecticides for malaria control. mol 7. One Health Initiative. Mission Statement. One healthinitiative.com/mission.php. Accessed July 8. Taylor LH, Latham SM, Woolhouse ME. Risk fac tors for human disease emergence. Philos Trans R Soc Lond B Biol Sci Chomel BB, Sun B. Zoonoses in the bedroom. 11. ership and risk factors for cardiovascular disease. Med J Aust 12. Beck AM, Meyers NM. Health enhancement and companion animal ownership. Annu Rev Public Health 13. services for the Army. Apr

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8 http://www.cs.amedd.army.mil/amedd_journal.aspx 14. 15. Smith KR, Corvalan CF, Kjellstrom T. How much global ill health is attributable to environmental factors?. 16. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury at tributable to 67 risk factors and risk factor clusters Lancet 17. 18. McCollum JT, Cronquist AB, Silk BJ, et al. Multi state outbreak of listeriosis associated with canta loupe. of national security. October21. AU T H OR S Joint Base Lewis-McChord, Washington. Region West, Joint Base Lewis McChord, Washington. US ARMY PUBLIC HEALTH ONE HEALTH, ONE MEDICINE, ONE TEAM

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January March 2015 9 When we hear the word terrorism, we often think of weapons of mass destruction. However, agroterrorism is another, even more insidious threat to our way of life. rorist acts intended to disrupt or damage a countrys ag riculture, especially the use of a biological agent against crops or livestock. 1 The threat is real. Evidence of such was discovered when American forces uncovered docu mentation that demonstrated Al Qaeda and the Taliban had extensive knowledge of agricultural diseases and the effects an agroterrorism attack would have on our food system. 2 According to Tim Downs, author of Ends of the Earth, 3 terrorists would most likely use genetically to infest crops, kill livestock, and sicken or kill humans. Potential agents that terrorists may use include bacteria, viruses, fungi, and invasive or nonnative insect species. Congress took action to protect our national food sup ply in the wake of the terrorist attacks on September 11, 2001, by passing the Public Health Security and Bioter rorism Preparedness and Response Act, 4 signed into law on June 12, 2002. Title III of the Act directed that the Presidents Council on Food Safety, in consultation with ty, the food industry, and consumer and producer groups, develop a crisis communication plan and an educational program that takes proactive steps to protect the national food supply from intentional acts of contamination. It directed that this strategy address threat assessments; technologies and procedures for securing food process ing and manufacturing facilities and modes of transpor communications to the public. Nearly 10 years later, the despite the best intentions of the Bioterrorism Act, the expenditure of billions of food defense dollars was not well coordinated. Testifying before a Senate committee on the matter, Lisa Shames, the GAO Director of Natu ral Resources and the Environment, stated There is no centralized coordination to oversee the federal govern ments overall progress implementing the nations food and agriculture defense policy. 5 This lack of centralized coordination of work by different agencies means that we as a nation are unsure that our efforts, and billions of our tax dollars are not being used wisely to counter agroterrorism. It also seriously hinders the implementa tion of effective, well-designed strategies to reduce the vulnerabilities of our nations agriculture to terrorists attacks. 5 In testimony before a senate subcommittee on counter-terrorism on September 14, 2011, John Hoffman, a former senior adviser in the Department of Homeland Security, made this sobering assessment: We may be blindsided by an intentional food-based attack on this nation sometime soon.... At present, our primary detec tion capability is the emergency room. 5 legislation aimed at preventing an attack rather than re sponding to one. 6 The Food and Drug Administration now has the challenge of shifting the perspective of pro is quite different in many ways and is a paradigm shift in how our nation protects its food supplies. The FDA Agroterrorism: The Risks to the United States Food Supply and National Security SFC Kevin M. Gill, USA AB S TR A CT Agroterrorism is a collective term that describes an intentional criminal attack against crops or mankind using viral, bacterial, fungal, or insect-borne agents. Agroterrorism also includes attacks against animals using infec tious pathogens such as Burkholderia mallei Bacillus anthracis and mouth disease, and several equine encephalitis viruses. Agents that could be used against crops include the causative agents of wheat blast, rice blast, rice brown spot disease, and wheat stem rust. The primary goal of terrorists using agroterrorism is to spread fear and cause massive economic loss. Subsequent goals include causing disease and death to humans and animals. The use of bioterrorism agents is a much more practical approach than using explosives, for example, to achieve those results since many of these biological agents are use of biological warfare dates back centuries and can still can be employed by terrorist groups, lone wolves, and political and religious groups to cause death and mayhem on a grand scale.

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10 http://www.cs.amedd.army.mil/amedd_journal.aspx proposed rule on food defense would require that food facilities take a proactive, targeted approach within their establishments that focuses on the progression of food processes where the intentional contamination of prod uct is most likely to occur. Effective efforts could then be implemented to best reduce those targets of oppor tunities. Finally, the proposed rule will require the larg est food operations create and implement a food defense plan. 6 Obviously, the US military is essential in defending this nation against threats from terrorists, whether in foreign environments or within our borders. As such threats have multiplied and evolved over the last decade, con cerns about protection of the food supply of the US mili tary have never been greater. Department of Defense 7 DoD Directive 6400.04E, DoD Instruction 2000.12, 9 DoD Instruction 2000.16, 10 Homeland Security Presidential Directives 7 11 and 9 12 13 are the framework within which the US Army Veterinary Service designs, grams to protect our military personnel and their fami lies. These programs include: Commercial food protection audits Installation food vulnerability assessments Food and water defense assessments for special events Food and water risk assessments overseas These directives and programs established global orga nizational policy and support for the prevention of inten tional contamination of our food supply and provide a framework from which we can provide the best possible protection for our food systems. BA CKGRO U ND Production and distribution of the food supply in the United States is one of the most complex systems in the world. The United States imports food from many na tions, some of which have ideologies that do not align with ours and may seek to do us harm. When this situa tion is paired with lax or nonexistent safety standards of some foreign countries, it clearly represents a potential threat to the US food supply. It is estimated that in 2010, more than 10 million food shipments were received from overseas manufacturers, and approximately only 1.6% received any type of federal inspection at the point of entry. 14 Imported foods make our food system vul nerable to terrorist attacks as these products may harbor disease or insect vectors that could spread and decimate tack on the US agriculture system could cause death and disease to Americans from coast to coast and result in devastating physical, economic, and, more importantly, psychological damage among our citizens. Terrorists re alize that the strength of our nation is its economy, and they are focusing more of their efforts on attacks that yield the most economic damage. The intentional contamination of food goes far beyond imported foods. To combat this threat, we must examine our food supplies from farm-to-fork. Farm-to-fork is the linear progression that food travels from the farm where it is grown and harvested, to the storage facilities while it waits for shipment, to the food manufacturers where it is processed and packaged, to retailers where it is sold, 15 Protecting such an ex tensive and complex system is a monumental task that requires diligence by professionals trained in food pro tection and hazard communications. Throughout this therefore the need for vigilance. In order to remain one of the safest food supply systems in the world today, we must employ at the local, state, and federal levels skilled professionals who are equipped to respond to and re cover from the crisis of an agroterrorism event. Over the last decade, the federal government has launched numerous initiatives to provide enhancements to the de fense of our national food supply. TH E TH RE A T duce immediate results, so terrorists have traditionally considered it to be a secondary tactic. It does, however, have the ability to spread fear and anxiety, produce large economics losses, create social instability, and result in foodborne disease outbreaks. It is most often used as act of economic sabotage rather than a violent act against animals or mankind. However, the use of agroterror ism is a much cheaper and easier alternative to building a dirty bomb, and would capture the attention of the entire nation for a long time. 16 Several factors have con tributed to the belief that terrorists could begin targeting our food supply. First, Al Qaeda leadership has been re duced dramatically over the last decade, leaving mostly low to midlevel terrorists who lack the ability to mount large-scale attacks. Second, economic harm to the Unit ed States remains one of the pillars of Al Qaedas net work. Third, microorganisms are inexpensive and can be cultured in clandestine labs by nearly anyone with a microbiology background. 2 Methodologies for cultur ing these pathogens can easily be found on the internet. Furthermore, many potential biological weapons occur naturally in the environment and do not require the use of laboratories. 16 AGROTERRORISM: THE RISKS TO THE UNITED STATES FOOD SUPPLY AND NATIONAL SECURITY

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January March 2015 11 MOTIV A TION Terrorists know that Americas strength lies with its economy and a successful attack on our nations food supply would be economically devastating for millions of its citizens. It could even affect our ability to project our military power abroad and lead to the overthrow of allied governments. Osama Bin Laden once bragged that the attacks on September 11, 2001, cost $500,000 dollars but caused more than $500 billion dollars in economic losses to the United States. 2 It is essential to understand what motivates an aggressor if we expect to generate effective risk mitigation strategies to stop acts of terror ism. The National Institute of Justice funded a research project to determine the extent a foot-and-mouth disease outbreak would have on the cattle industry in the state of Kansas. 17 The study found that those who would attack our agriculture fall into one of 4 categories : 1. International terrorists 2. Economic opportunists 3. 4. Militant animal rights groups Terrorists are typically politically or ideologically mo tivated and they may work alone or in small organized groups. Economic opportunists use agroterrorism to manipulate markets and exploit the situation for their tivated by a sense of revenge for some real or perceived wrongdoing, and they actually pose a greater risk than most other aggressors as they are likely to be less scru tinized due to their legitimate reason for being on the premises. Militant animal rights activists, such as the Earth Liberation Front, are motivated by a moral obliga tion to prevent animal abuse and have committed more than 2,000 crimes costing an estimated $110 million on the FBIs domestic terrorism threats in 2004. INCIDENT S O F AGROTERRORI S M There are many recorded examples of agroterrorism in history dating from the sixth century BC when Assyr ian forces poisoned well water with rye ergot. During World War I, German forces attempted to infect horses bound for Europe from the United States with glanders Burkholderia mallei (Bacillus anthra cis) 2 While glanders is a bacterial disease that primar ily affects horses, it and anthrax can spread to humans, donkeys, mules, and other mammals. 19 The single larg est biological terrorist attack ever occurring on US soil poisoning their opponents and thereby causing a lower voter turnout. The cult did so by cultivating Salmonella typhimurium in a covert laboratory on their ranch and spreading the potentially dangerous pathogen on bath cal town of The Dalles. Just prior to election day, emer gency rooms, hospitals, and clinics were overrun with people suffering from extreme nausea and diarrhea. The attack sickened 751 people, but fortunately there were no fatalities. 20,21 Cochlio myia hominivorax States/Mexico border in an attempt to spread this para sitic problem and keep their jobs in a screw worm eradi cation program. 16 In 1996, animal feed was the target of disgruntled work ers at a rendering plant when a cow carcass was inten tionally contaminated with the pesticide chlordane. The lbs of feed which found its way onto 4,000 dairy farms in 4 states, and resulted in a dairy food recall that cost the industry an estimated $250 million loss. 22 In 1997, economic opportunists adulterated spent ani mal grease from local restaurants intended for chicken feed with a fungicide. This criminal act was perpetrated by a rival feed company owner, and the investigation and apprehension of the suspect required the concerted 22 In 2003 a disgruntled meat department employee was arrested for intentionally contaminating an estimated 200 lbs of ground beef with a nicotine-based insecticide known as Black Leaf 40. The Centers for Disease Con trol and Prevention reported that 92 individuals became ill with symptoms including burning of the mouth, nau sea, vomiting, and dizziness. 23 In 2014 Japanese factory worker Toshiki Abe was sen tenced to 3.5 years in prison for intentionally contami nating frozen food products with the pesticide malathi on. Detected concentration levels of this poison were 2.6 million times higher than what is permitted by law. The processor of these frozen food products does not use the insecticide malathion, so the presence of this toxic sub stance at such a high concentration is proof of a deliber ate act. Abes actions sickened nearly 900 persons. This case is one of the largest proven acts of intentional food product contamination. 24

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx FOOT-A NDMO U T H DI S E AS E The 2005 National Institute of Justice study categorized agriculture. This viral disease is 20 times more contagious than small pox and causes painful sores on the hooves and mouths of cloven-hoofed animals such as cattle, pigs, sheep, goats, and deer. These sores are so debilitating that the animals are unable to walk, eat, Although humans are not affected by FMD, they can exposure, and the spread from animal to animal can extend as far as 50 miles. An outbreak of FMD in the United Kingdom in 2001 affected 9,000 farms and re quired the destruction and disposal of more than 4 mil lion animals. That outbreak cost the United Kingdom an estimated $21 billion dollars. A similar outbreak in the United States would cost more than $60 billion dollars. Not only would such an event have a dramatic effect on the availability of meat products in the United States, it could also halt exports to other countries for years in the future. The loss of jobs would be devastating and result in billions of dollars in economic costs. 2 The sequence for dealing with FMD as presented in the National Institute of Justice study includes the use of law enforcement to establish a strict quarantine around the affected area, roadblocks established to exclude sick animals and prevent contaminated vehicles from leav ing the area and spreading the infections, and sound crime scene investigation procedures. An outbreak of FMD would require a quarantine area 6 miles in radi us and last at least 30 days. Roadblocks would have to be strategically placed along all thoroughfares leading from the point-of-origin of the outbreak outward in all directions. Law enforcement must conduct interviews with drivers to determine if the passengers had recently been in a contaminated area. If so, stations manned by trained personnel would have to be established close to the roadblocks to allow for the proper decontamination of both vehicles and persons. Crime scene investigators would be responsible for collecting tissue samples and hoofed animals in the affected area would have to be destroyed and disposed of properly. 25 This would be an enormous undertaking that not many of our local and Clearly, the value of preventing FMD outbreaks using sound biosecurity measures far outweighs the monu mental task of containing such an event. VU LNER A BILITIE S According to the National Defense Research Institute, there are several key factors that make US agriculture particularly vulnerable to attack. 26 First, the farms that produce our food have become ever more concentrated and rely on old fashioned farming practices. This con centration of animals into relatively small areas greatly containment situation. Second, livestock are more sus ceptible to disease infection due to husbandry tactics and the overuse of antibiotics. Such tactics include ster ilization programs, dehorning, and even hormone injec tions. The overuse of antibiotics causes many pathogen ic bacteria to develop resistance to therapy. Third, most farms are devoid of any real, organized surveillance detection systems. Animal feed lots and barns are often left unguarded and therefore indefensible. Fourth, the passive reporting system that farmers are expected to use when they discover an animal suspected of having a communicable disease relies on the farmer to self-re port the suspected diseased animal to authorities. Such a system puts farmers in an awkward situation which can negatively impact their livelihood and forces them into a shoot, shovel, and shut-up mindset in fear the gov ernment may condemn their entire livestock if they ever found out. The last factor is the lack of veterinarians in to recognize and properly diagnose animal diseases that are not commonly found in this country. PROTECTION O F T H E MILIT A RY FOOD SY S TEM Ever since the terrorist attacks on the World Trade Cen ter on September 11, 2001, our countrys leaders recog nized that an attack on our food supply could threaten our very existence. Much has changed to protect our na tional food supply since the then Secretary of Health and Human Services, Tommy Thompson, said in 2004 I, for the life of me, cannot understand why the terrorist have not attacked our food supply, because it is so easy to do. 27 The Bioterrorism Act of 2002 4 supplied the impe tus for DoD Directive 6400.04E which assigned to the US Army Veterinary Service the overarching authority to execute food defense programs within the DoD. DoD Directive 6400.04E also mandates the standardization of commercial food protection audits, installation food vulnerability assessments, food and water defense as sessments, and food and water risk assessments. The Veterinary Services Portfolio of the Army Institute of Public Health is charged with providing a proactive ap proach to protect military food systems and deny terror ists the ability to attack those food supplies. It met this food establishments both on and off installations wher ever military service personnel are stationed. These ex perts do so by working closely with the United States Department of Agriculture, Food and Drug Administra AGROTERRORISM: THE RISKS TO THE UNITED STATES FOOD SUPPLY AND NATIONAL SECURITY

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January March 2015 13 installation garrison commanders to identify potential weak areas in food systems and offer simple and costeffective strategies to reduce or eliminate such vulner abilities. Further, standardized inspections of food de liveries and storage areas are conducted on a regular basis by personnel who have been specially trained in food defense by the Army Medical Department Center & School. This determined effort is integral in prevent ing and detecting the intentional contamination of food systems by terrorists using conventional chemical, bio logical, radiological, nuclear, or physical agents. The threat of the intentional contamination of the mili tary food supply is much more complex in deployed environments and presents an increased level of dan ger in terms of possible nonbattle injuries and poten tial mission failures. The major challenge to preventing terrorists from using agroterrorism is that food distri bution systems are quite expansive and therefore food protection programs designed to protect them are very expensive, both in terms of personnel and dollars. Such systems must protect nodes along a sizeable geographi cal area and take into consideration susceptibilities of food transported over potentially hostile territory with numerous handlers. It must also take into account food processes such as mixing of large batches, short prod uct shelf-life, and global distribution. This is quite am bitious, even in the relative safety of the United States, and as author Tim Downs says, The concern about an agricultural act of terrorism is we just cant defend a thousand-acre farm, he explains. You can put up a metal detector in an airport but how do you protect a thousand acres of corn or wheat? 3 The DoD has several initiatives in place to improve the defense posture of our food supply such as commercial food protection audits, installation food vulnerability assessments, food and water defense assessments, and food and water risk assessments. The food protection audit was enacted to systematically evaluate the food defense programs of commercial food facilities supply ing subsistence to the DoD. These approved food fa cilities provide a large portion of the subsistence in the efforts taken to prevent adulteration at Meals Ready-toInstallation food vulnerability assessments provide in posture of all food facilities on an installation at any given time. The assessments are directly tied to cur rent force protection condition measures and results are briefed to ATOs and installation commanders using the deliberate risk assessment model. Additionally, these re sults are used to develop the Veterinary Service annex to the installation emergency response plan. Incorpora tion of these assessments into the installation emergency response plan helps all key players understand the vital role that food defense personnel play during an actual emergency. Food and water defense assessments at special events of food and water during large gatherings of DoD per sonnel. Veterinary Service personnel work closely with other public health entities and the installation ATO to identity vulnerabilities at these events and make recom mendations that will effectively mitigate those hazards. Food and water risk assessments were developed to ad in foreign countries hosting military exercises. In these situations, access to foods from approved sources is ex intent of regulatory requirements. Highly-trained DoD public health specialists assess the risks associated with consumption of food from caterers, restaurants, and lo cal host nation food facilities. These assessments are not inspections and do not produce a pass or fail but rather determine for operational commanders the ex pected overall risk exposure for their personnel if these establishments are used. CONCL US ION Thanks to the cooperative efforts of multiple local, state, and federal agencies across the country, we still have the safest food supply in the world. These public health professionals provide technical expertise throughout the continuum of the food supply chain from farm-to-fork. The defense of our nations food and agriculture resourc es is now fully integrated in the day-to-day mission of US Army Veterinary Service personnel. The DoD mis sion will continue to change and budget constraints will inevitably challenge these professionals in their mis sion to ensure that critical resources are protected from those who mean us harm. Our collective national effort to support the safest food supply in the world will re main highly effective utilizing the systemic approaches developed by US Army Veterinary Service personnel to anticipate, detect, and mitigate our enemies attempts to strike our food supply. RE F ERENCE S 1. Oxford Dictionary [online]. Oxford University Press. 2014. Available at: http://www.oxforddic tionaries.com/definition/english/agroterrorism. Accessed December 11, 2014.

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14 http://www.cs.amedd.army.mil/amedd_journal.aspx 2. Olson D. Agroterrorism: threats to Americas economy and food supply. Federal Bureau of In vestigation Web site; 2012. Available at: http://leb. fbi.gov/2012/february/agroterrorism-threats-toamericas-economy-and-food-supply. Accessed De cember 11, 2014. 3. Downs T. Ends of the Earth Nashville, TN: Thom as Nelson, Inc; 2009. Cited by: Homeland Security News Wire [serial online]. Agro-terrorism threat is real. September 3, 2009. Available at: http://www. homelandsecuritynewswire.com/agro-terrorismthreat-real. Accessed December 11, 2014. 4. Public Health Security and Bioterrorism Prepared RegulatoryInformation/Legislation/ucm155769. htm. Accessed December 12, 2014. 5. Bottemiller H. GAO: Lack of coordination for U.S. food defense. Food Safety News [serial online]. September 16, 2011. Available at: http://www.food safetynews.com/2011/09/gao-lack-of-coordinationfor-us-food-defense/. Accessed December 11, 2014. 6. FDA Food Safety Modernization Act, Pub L No. www.fda.gov/Food/GuidanceRegulation/FSMA/ default.htm. Accessed December 22, 2014. 7. Department of Defense 5200.08 : Physical Security Program Washington, DC: US Dept of Defense; May 2009. Available at: http://www.dtic.mil/whs/ cember 22, 2014. Department of Defense Directive 6400.04E: DoD Veterinary Public and Animal Health Services Washington, DC: US Dept of Defense; June 2013. Available at: http://www.dtic.mil/whs/directives/ corres/pdf/640004E.pdf. Accessed December 22, 2014. 9. Department of Defense Instruction 2000.12: DoD Antiterrorism (AT) Program Washington, DC: US Dept of Defense; September 2013. Available at: http://www.dtic.mil/whs/directives/corres/pdf/200 012p.pdf. Accessed December 22, 2014. 10. Department of Defense Instruction 2000.16: DoD Antiterrorism (AT) Standards Washington, DC: US Dept of Defense; December 2006. Available at: http://www.dtic.mil/whs/directives/corres/pdf/200 016p.pdf. Accessed December 22, 2014. 11. Homeland Security Presidential Directive 7: Criti Protection. Washington, DC: The White House. December 17, 2003. Available at: http://www.dhs. gov/homeland-security-presidential-directive-7#1. Accessed December 22, 2014. 12. Homeland Security Presidential Directive 9: De fense of United States Agriculture and Food. Wash ington, DC: The White House; January 30, 2004. Available at: http://www.gpo.gov/fdsys/pkg/PPP2004-book1/pdf/PPP-2004-book1-doc-pg173.pdf. Accessed December 22, 2014. 13. paredness. Washington, DC: The White House. March 30, 2011. Available at: http://www.dhs.gov/ ness#. Accessed December 22, 2014. 14. Racino B. Flood of food imported to United States, but only 2 percent inspected. NBCNEWS.com [se rial online]. October 3, 2011. Available at: http:// www.nbcnews.com/id/44701433/ns/health-food_ safety/t/flood-food-imported-us-only-percent-in spected/. Accessed December 22, 2014. 15. Oxford Dictionary [online]. Oxford University Press. 2014. Available at: http://www.oxforddic tionaries.com/us/definition/american_english/ from-farm-to-fork-or-table-. Accessed December 22, 2014. 16. Keremidis H, Appel B, Menrath A, Tomuzia K, Normark M, Roffey R, Knutsson R. Historical per spective on agroterrorism: lessons learned from 1945 to 2012. Biosecur Bioterror cember 11, 2014. 17. Knowles T, Lane J, Bayens G, Speer N, Jaax J, Carter D, Bannister A. NIJ Research Report: De ican Agriculture from Agroterrorism Washington, DC: National Institute of Justice; June 30, 2005. Masters J. Militant extremists in the United States [internet]. Council on Foreign Relations Web site. February 7, 2011. Available at: http://www.cfr.org/ terrorist-organizations-and-networks/militant-ex tremists-united-states/p9236#. Accessed Decem ber 22, 2014. 19. Centers for Disease Control and Prevention. Glan ders. CDC Website. Available at: http://www.cdc. gov/glanders/. Accessed December 22, 2014. 20. Zaitz L. Rajneeshees in Oregon the untold sto ry [internet]. The Oregonian February 14, 2014. Available at: http://www.oregonlive.com/rajneesh/ index.ssf/2011/04/part_one_it_was_worse_than_ we.html. Accessed December 22, 2014. 21. Torok TJ, Tauxe RV, Wise RP, et al. A large com munity outbreak of salmonellosis caused by in tentional contamination of restaurant salad bars. JAMA AGROTERRORISM: THE RISKS TO THE UNITED STATES FOOD SUPPLY AND NATIONAL SECURITY

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January March 2015 15 22. What are some examples of agroterrorism?. Ex tension.org Website. April 26, 2010. Available at: https://www.extension.org/pages/37146/what-aresome-examples-of-agroterrorism. Accessed De cember 22, 2014. 23. Center for Disease Control. Nicotine poisoning after ingestion of contaminated ground beef Michigan, 2003. MMWR Morb Mortal Wkly Rep Accessed December 22, 2014. 24. Lui M. Frozen foods in pesticide recall sicken 900 in Japan, NHK says. Bloomberg News [serial on line]. January 17, 2014. Available at: http://www. in-pesticide-recall-sicken-900-in-japan-nhk-says. html. Accessed December 22, 2014. 25. Schmitt G. Agroterrorism-why were not ready: a look at the role of law enforcement. NIJ Journal journals/257/pages/agroterrorism.aspx. Accessed December 22, 2014. 26. National Defense Research Institute. Agroterror ism. What is the threat and what can be done about it? [internet]. Rand Corp Web site. 2003. Research Brief. Available at: http://www.rand.org/content/ dam/rand/pubs/research_briefs/2005/RB7565.pdf. Accessed December 22, 2014. 27. Branigin W, Allen M, Mintz J. Tommy Thomp son resigns From HHS. WashingtonPost.com [serial online]. December 3, 2004. Available at: http://www.washingtonpost.com/wp-dyn/articles/ A31377-2004Dec3.html. Accessed December 22, 2014. AU T H OR SFC Gill is a Veterinary Services Senior Noncommis of Public Health, US Army Public Health Command, Ab erdeen Proving Ground, Maryland.

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx BA CKGRO U ND Each year, foodborne diseases cause an estimated 48 million illnesses in the United States, with an estimated 9.4 million caused by 31 major pathogens. 1-3 Relatively few foodborne illnesses are associated with an outbreak, agent or food product. Given the potential impact of a foodborne illness outbreak and the resultant negative effect on mission readiness and national security, the military employs several programs aimed at protecting the food supply. 4 These programs operate on many lev els from acquisition to consumption, with the objective of providing broad, overall protection from foodborne pathogens and contamination. As part of this overall goal, the US Army Public Health Commands (APHC) Destination Monitoring Program was developed as an active food surveillance program with the primary goal of verifying the effectiveness of food safety systems and providing primary prevention against foodborne disease. 4 The Army Institute of Public Health Veterinary Ser vices (AIPH-VS) is responsible for operating the Des tination Monitoring Program, illustrated in Figure 1. The AIPH-VS determines, on a quarterly basis, what types and how many food items should be collected and submitted from all regions and districts within those re gions (COL T. Honadel, oral communication, December 11, 2013). Leadership at the district level assigns sam pling to each installation and facility within that district. Veterinary Food Inspection Specialists assigned to these installations then select, collect, prepare, and ship food samples to the Food Analysis Diagnostic Laboratory (FADL) at Joint Base San Antonio Fort Sam Houston, Texas. The FADL performs testing on the food samples according to published guidelines. 5,6 The FADL is ac credited by the American Association for Laboratory microbial and chemical tests. Samples that test positive for zero tolerance pathogenic organisms are reported ell, email, November 7, 2014). All laboratory results are then loaded into the Veterinary Services Lotus Notes database, an internal database used for tracking animal health and food safety within the APHC. Positive test results are sent back to the submitter, the region, and the AIPH-VS (Dr R. Benisch, oral communication, Decem ber 11, 2013). The district headquarters of the submit of sampling accuracy, to include food processor name, Evaluation of the US Army Institute of Public Health Destination Monitoring Program, A Food Safety Surveillance Program MAJ Kamala Rapp-Santos, VC, USA Karyn Havas, DVM, PhD Kelly Vest, DVM, DrPH, MPH AB S TR A CT The Destination Monitoring Program, operated by the US Army Public Health Command (APHC), is one com ponent that supports the APHC Veterinary Services mission to ensure safety and quality of food procured for the Department of Defense (DoD). This program relies on retail product testing to ensure compliance of production facilities and distributors that supply food to the DoD. This program was assessed to determine the validity and were representative of risk, and whether the program returns results in a timely manner. Data was collected from the US Army Veterinary Services Lotus Notes database, including all food samples collected and submitted from APHC Region-North for the purposes of destination monitoring from January 1, 2013 to December 31, 2013. For most food items, only one sample was submitted for testing. The ability to correctly identify a contaminated food is low. The food groups most frequently sampled by APHC correlated with the commodities that were implicated in foodborne illness in the United States. Food items to be submitted were equally distributed among districts and branches, but sections within large branches submitted relatively few food samples compared to sections within smaller branches and districts. Finally, laboratory results were not available for about half the food items prior to their respective expiration dates.

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January March 2015 17 processing plant location, lot/production code, and product size. A number of actions may occur in re sponse to a positive test result, depending on whether the nonconforming result is due to a pathogenic organism such as Sal monella spp or Escherichia coli O157:H7, an indicator organism shown by total coli forms or psychrotrophic count, or another measure of food quality or safety such as mercury or pH. The AIPH-VS evaluates the potential risk to public health, and collaborates with DoD procurement agen cies when determining if a product should be recalled or if the manufacturing plant should be suspended. The AIPH-VS also appropriate regulatory agency in the case of a pathogen positive result (COL T. Hon adel, oral communication, December 11, 2013). Nonconforming results typically will result in scheduling of a directed food protection audit of the commercial estab lishment, and additional food samples may be collected and tested. 7 The Destination Monitoring Program has several goals, an important one of which is to ensure that food procured by the resources, this is best accomplished by testing the foods that present the greatest risk of contamination with pathogens that cause the most severe illnesses. As the DoD procures a wide variety of food items for consumption by military sure that many different items are tested to adequately represent all military installations. Finally, the program is enhanced when all personnel involved in food sam pling and testing receive adequate training, especially considering the wide variety of food items procured by that are requested for testing, which may not necessarily of the program (COL T. Honadel, oral communication, May 6, 2014). However, achievement of all goals, espe cially in the context of limited resources, may not be possible, and prioritization will help determine the best methods to conduct the program. This assessment was focused on the goal of identifying and testing high-risk food items with the purpose of ensuring food safety and preventing foodborne illness. The objective of this study was to evaluate the processes currently utilized by the APHC to identify, collect, and submit food samples for laboratory testing, and assess them for validity and timeliness. Focus was primarily on 3 processes: (1) assessment of sample size and dis cussion of how sample size relates to statistical power of food samples to be tested and discussion of the risk of foodborne illness associated with different types of especially regarding the timing of sample submission, reporting of results, and expiration of the food product. The Uniformed Services University of the Health Sci MET H OD S Study Design A descriptive analysis of the Destination Monitor ing Program was performed to assess validity and Figure 1 Overview of the Destination Monitoring Program Sample selection and testing. Army Institute of Public Health PHC District PHC Region Veterinary Services Branch Database Food Analysis and Diagnostic Lab FLAGGEDITEMNOTIFICATIONPaperwork Damaged Sample Issue Quarterly Sample Directives Assign Samples Assign Samples Record Results Record Results

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18 http://www.cs.amedd.army.mil/amedd_journal.aspx timeliness of the program. Assessment of the program occurred within the APHC Veterinary Services, which both implements the program and has oversight of the veterinary personnel who execute the program at the re gion, district, and branch levels. Analysis was limited to existing data from the US Army Veterinary Services Lotus Notes database provided by the AIPH-VS, which consisted of laboratory results and administrative information on food samples collected, submitted, and tested from January 1, 2013 to Decem ber 31, 2013. The analysis was limited to samples col lected from the veterinary branches that fall under the purview and command of Fort Belvoir, Fort Eustis, and Fort Knox Districts within APHC Region North (APH CR-N). The data consisted of sample request forms sent to the FADL, which list administrative information (dis the sample collection (location, date collected/submit ted), sample characteristics (brand, category of food, weight, number of samples, expiration, plant code), and information from the laboratory (date received, errors, laboratory results). All data was manually extracted from the Lotus Notes IBM SPSS Statistics 22 was used for the descriptive analyses. Evaluation of Sample Size Descriptive statistics were obtained on the number of food samples collected and tested to determine the ap that could be expected. This information was used to develop an operating characteristic curve, which relates the probability of concluding a food lot is safe to the ceptable level based on sample size. 8 Operating charac teristic (OC) curves are frequently used in development and assessment of sampling plans, and the process is well documented in the literature. 8-11 They are based on the probability of detecting a contaminated lot based on a number of factors, including level of contamination in the source lot, the number of positive samples desired in order to reject the lot, and the mean and standard devia tion of the bacterial concentration in the source lot. In this assessment, the sample size (n) evaluated was based on the median number of sample units (c) selected from each lot. The maximum allowable number of sample units that could test positive for an organism before a lot was rejected was set to zero, as is typical for pathogens. Mean bacterial concentration was converted to a loga rithmic scale, with a standard deviation of 0.8 colonyforming units per gram (cfu/g). This standard deviation was selected based on use in the literature to represent typical distribution of bacteria in a heterogeneous solid food. 9-11 E Coli is a common indicator organism, there fore, a hypothetical example using detection of E Coli in fresh fruits and vegetables, with an acceptable limit of less than 10 cfu/g (log 1 cfu/g) was considered. The desired acceptance level was designated at 5%, meaning if it rejected a contaminated lot 95% of the time. For comparison, OC-curves were also constructed to depict samples drawn from each lot was increased to n=2, 5, and 10. Representative of Risk To determine if the food items selected as part of the Destination Monitoring Program were representative of the risk of foodborne illness, the frequency and percent age of items tested were determined by food category, as and percentage of positive results were tabulated for by APHCR-N, all food items tested were recategorized according to 17 food commodity groups, based on the nature of the food source and ingredient, as developed by Painter, et al. 1,12 Some items were categorized into more than one of the 17 food commodities if they contained more than one ingredient. 12 Frequency and percentage of food items tested by district and branch were also tabu lated. Microbial and chemical testing was summarized by tabulating the number of food items that were tested for each organism or chemical. Timeliness Timeliness of the program was determined by using the median days that elapsed from when the food items were submitted to laboratory and when the results were available. Additionally, the median time from when laboratory results were available to when the food item expired was calculated. Median values were selected due to the skewed distribution of values as well as to minimize the effect of outliers. RE SU LT S Evaluation of Sample Size A total of 668 food samples from APHCR-N were col lected and submitted to the FADL for the Destination Monitoring Program in 2013. Of those, 577 (86.4%) were actually tested by the FADL. Duplicate samples submitted for the same item were often not tested un less required by FADL, such as when needed for ad ditional chemical testing or to meet minimum weight requirements for microbial sampling (R. Leo, oral com munication, May 20, 2014). The submitted food samples EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM, A FOOD SAFETY SURVEILLANCE PROGRAM

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January March 2015 19 comprised 514 individual food items. The majority of food items submitted and tested contained one sample (73.5%, 89.2% respectively). The number of samples submitted and tested per item ranged from one to 8, with a median of one. Seven items were submitted but not tested at all. Of those not tested, 3 were not received and 4 were not tested due to lost integrity of packaging (broken, leaking). The distribution of number of sam ples submitted and tested for each food item is shown in Table 1. As the median number of samples submitted and tested was one, the OC-curves were constructed using n=1 and c = 0 (Figure 2). The probability of accepting a lot differed depending on the sample size (n) and the pro the proportion of contamination within the lot was 10%, there is a 90% probability of accepting the lot based on the negative results of that one sample. This probability decreased in a linear fashion as the level of contamina tion increased. At 50% contamination, the lot is accept ed 50% of the time with a sample size of one. In contrast, when the sample size was increased to n=5, and if the proportion of contamination within the lot was 10%, the probability of accepting the lot is 59%. At a contamina tion level of 50%, the probability of accepting the lot based on 5 negative samples is reduced to 3% (Figure 3). A comparison of the probability of accepting a lot based on a variety of levels of contamination and several hy pothetical sampling plans is presented in Table 2. Representative of Risk The AIPH-VS requested food items from 14 food cat egories during 2013. The food groups represent cat egories of interest as they are considered potentially hazardous foods and give guidance to veterinary per sonnel in selecting items off the shelf (Table 3). Of the 507 food items collected and tested, the individual cat egory with the most items tested was ground meat based on food origin, 35.1% of the food items consisted of fresh fruits and vegetables. This in cluded processed fruits and vegetables (12.2%), bagged salads (12%), and whole fresh fruits and cant representation included prepared salad (9.5%), kimchee/tofu (5.7%), and raw seafood (5.5%). Over the period of one year, 3 food items tested positive for indicator organisms. This included one liquid dairy item, which represented 4.4% of all fresh dairy items tested, and 2 unprocessed fresh fruit and vegetable items, representing 3.6% of all items in that category tested. The frequencies of microbial and chemical testing on food samples were determined. Of the pathogenic bac teria, tests for the presence of Salmonella spp were most frequent (n=350, 69%). Testing for other pathogenic bac teria included Listeria monocytogenes (n=323, 63.7%), Staphylococcus aureus (n=315, 62.1%), and E Coli O157:H7 (n=232, 45.8%). Tests for indicator organisms included E Coli (n=403, 79.5%), total coliforms (n=270, 53.3%), and psychrotrophic count (n=83, 16.4%). Three food samples tested positive for indicator organisms (Table 3), including whole bagged salad and dairy. The dairy food item tested positive for both total coliforms and standard plate count. The total number of food items requested by AIPH-VS was similar for each district, and were evenly assigned across the branches and sections within each district. Table 1 Comparison of Number of Samples Submitted and Tested by the Department of Defense Food Analy sis Diagnostic Laboratory for the Destination Monitoring Program, January 1 December 31 2013 Number of Samples Submitted Tested Total number of samples 668 577 a Median samples per item 1 1 Minimum samples per item 1 1 Maximum samples per item 8 8 Number of Items Total N=514 N=507 b n(%N) n(%N) Items containing 1 sample 378(73.5%) 452(89.2%) Items containing 2 samples 127(24.7%) 49(9.7%) Items containing 3 samples or more 9(1.8%) 6(1.2%) a Duplicate samples submitted for the same item were often not tested except in certain cases such as chemical analysis to meet minimum weight requirements for microbial testing. b Seven items were not tested (not received or suspect package integrity). Figure 2. Based on sample size of one, the probability of accepting a contaminated lot decreases in a linear fashion as the level of con tamination in the lot increases. 1.00 0.80 0.60 0.40 0.20 0.00 0.80 0.60 0.40 0.20 0.00 1.00 P(acceptance)=90% P(acceptance)=50% Proportion Defective Probability of Acceptance

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx Some sections in large districts, such as Fort Belvoir District, were assigned a rela tively small number of food items to collect compared to sections in smaller districts (Table 4). For example, the Fort Knox com missary collected a greater total number of food items (10.7%) compared to other larger commissaries in the region, such as Fort Belvoir (1.8%). Timeliness The median number of days elapsed be tween food sample submission to the FADL and availability of laboratory results was 9 days, ranging from 1 to 49 (Table 5). For those food items that had an expiration date (n=424), the median number of days between availability of laboratory results and expiration of the product was 2 days, and ranged from -26 (product expired 26 days before laboratory considering items with an expira tion date, 46.7% of food items ex pired before or on the same day that laboratory results were reported. In many cases, these items represent highly perishable foods with a short shelf life. Figure 4 depicts the distribution of days elapsed between date of submission and laboratory results. COMMENT The purpose of this evaluation of the APHCs Destina tion Monitoring Program was to determine the effec tiveness, timeliness, and validity of the program and to inform stakeholders and policymakers on the strengths and limitations of the program. Most food item submissions contained only one food sample. Even if two or more samples were submitted, often only one sample was actually tested. By selecting tial to fail to detect a contaminated lot, even when the to detect with a sampling plan that includes collection of only one sample. However, increasing the sample size even moderately would greatly increase the prob ability of correctly identifying contaminated lots. Tak ing a single sample, particularly if negative, affords virtually no ability to discriminate between conforming and nonconforming lots. 10 Recommendations include collecting more samples of each requested item from each commissary. If current inventory will not allow this, sample collection could be co ordinated among commissaries in each branch, to allow for collection of samples from the same lot, or at least the same brand with similar production dates. The program was also evaluated to determine if the food items selected for testing adequately represented the risk of foodborne illness. The AIPH-VS makes the decision on what cat egories of food to test based on a variety of factors, such as recent food recalls, reports of foodborne illness at tributed to certain foods, past knowledge of contaminat ed food items, and training needs (Dr R. Benisch, oral communication, December 11, 2013). Although a formal, objective risk assessment process has never been devel oped to assist in determining what food categories pose the greatest risk to consumers, the food categories se lected for testing in 2013 did appear to represent those food categories most often implicated in foodborne disease outbreaks, as assessed by Painter et al. 1 Only 3 food items tested positive for contaminants during the study period, which is too few to accurately assess or recommend what food categories are historically asso ciated with increased risk of contamination within this system. A more extensive study reviewing several years these recommendations. Development of a formal risk on publications such as those that track foodborne illness by food category, food items produced from commercial during sanitation audits, data from the All Food and Drug Activities announcements released by the Defense Logistics Agency, etc. Table 2. Probability of Accepting a Lot in Relation to Proportion of Contamination and Sample Size. Proportion of Contamination Sample Size n=1 n=2 n=5 n=10 10% 0.9 0.81 0.59 0.35 20% 0.8 0.64 0.33 0.11 50% 0.5 0.25 0.03 0.01 Figure 3. When 5 samples are tested, the probability of accepting a con taminated lot decreases drastically as the level of contamination increases, greatly reducing the risk of allowing a contaminated food item to remain avail able to consumers. 1.00 0.80 0.60 0.40 0.20 0.00 0.80 0.60 0.40 0.20 0.00 1.00 P(acceptance)=3% P(acceptance)=59% Proportion Defective Probability of Acceptance EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM, A FOOD SAFETY SURVEILLANCE PROGRAM

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January March 2015 21 Although each district in the study collected a similar distribution of products, there was a large difference when comparing individual sections. This was because some districts, such as Fort Belvoir, are comprised of many more sections responsible for more commissar ies. The current program allows for representation of many facilities, but the proportion of samples collected at each facility is not based on the size of the facility nor the population served at each facility. Re adjusting the number of samples requested of contamination and proportion of people served at each facility would improve the representation of samples requested. This would require information on the relative size of each facility, number of patrons served, and number of veterinary person nel assigned to support each facility. Finally, this evaluation examined the time liness of the program. Most laboratory re sults were reported within 15 days. Food items typically arrived at the FADL within one business day, and FADL personnel did not indicate an overwhelming burden of samples. In fact, the majority of the time lapse between sample submission and report ing of results was likely due to typical pro cessing associated with conducting labora tory tests. Due to the nature of some perish able food items, almost half of items sampled expired before results were reported. Many of the highly perishable food items are also considered a higher risk, potentially hazard ous food. Thus, they should continue to be included in the program, with the recognition that if a positive laboratory test is reported, the food lot from which the sample was taken will no longer be available for purchase, and may in fact already be consumed or discard ed. Procedures should be developed to inform military public health personnel of the poten tial health threat. Further, program manag ers should consider the value of additional laboratory support through the use of satel lite facilities or contracted civilian laborato ries. This may allow for more rapid testing of highly perishable food items, and may be collection is pursued. Analysis of the destination monitoring pro gram revealed several strengths. First, al though the program does not employ a for mal risk analysis process to determine what food items should be collected, the data suggest that the informal process based on current trends and subject matter ex pertise resulted in selection of a variety of food items representing a moderate to high potential for contami nation. Second, the shipping and processing of food items happened quickly, and results were reported in a timely manner. Lastly, recent accreditation of the FADL Table 3: Distribution of Unique Food Samples Collected and Tested Based on Category, and Number of Items Positive for Indicator Organisms. Food Category Food Items Tested, N=507 n(%N) Food Items Positive for Indicator Organisms, N=507 n(%N) Proportion Positive Within Category Ground meat 78(15.4%) Processed fruits and vegetables 62(12.2%) Bagged salad 61(12.0%) Whole fresh fruits and vegetables 55(10.9%) 2(0.4%) 3.60% (n=55) Prepared salad 48(9.5%) Frozen dairy 30(5.9%) Other PHF (kimchee/tofu) 29(5.7%) Raw seafood 28(5.5%) RTE meats 23(4.5%) Fresh liquid dairy 23(4.5%) 1(0.2%) 4.40% (n=23) Powdered infant formula 22(4.3%) Cheese 21(4.1%) Seafood fresh RTE 19(3.8%) Seafood (canned RTE) 8(1.6%) Total 507(100%) 3(0.6%) PHF indicates potentially hazardous food. RTE indicates ready-to-eat. Figure 4. Days from the date of sample submission to the date results were available. 49 22 24 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 3 1 180 160 140 120 100 80 60 40 20 0 Frequency Days

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22 http://www.cs.amedd.army.mil/amedd_journal.aspx procedures used to determine contami nation in submitted food items. Several limitations of the program were cant limitation was the reliance on small sample sizes to make decisions about the safety of food lots. Additionally, al though the Lotus Notes database was and did not provide an easy method to extract data for analysis. All records had to be individually accessed and tran scribed to an Excel worksheet for analy sis. Currently, the database does not pro vide an easy way for users to evaluate data from an epidemiologic perspective. The program is also not well integrated with other surveillance systems, such as the Armed Forces Reportable Medi cal Events passive surveillance system 14 or the Centers for Disease Control and Prevention FoodNet 15 or PulseNet 16 systems. It should be noted that while FADL does not directly communicate with other surveillance systems, it does send samples from food items testing positive for zero-tolerance pathogens to the Texas State Department of Health, which communicates with PulseNet tion, November 7, 2014). Improving the communication and integration between the AIPH-VS and other foodborne dis ease surveillance systems as well as oth er military public health infrastructure may be vital in linking human disease cases to potential foodborne pathogens detected within the Destination Moni toring Program. Although this analysis was limited to the APHC Region North, many conclusions will likely apply to the same type and number of food items are typically requested from each re gion, and food samples are all processed at FADL. However, one would expect the distribution of sample collection to vary between individual sections. Addi tional research may give more informa tion as to how the program functions in and Europe. Table 4. Frequency of Food Item Submissions by District, Branch, and Section of the APHC Region-North, January 1 December 31 2013 District Branch Section Frequency % of District Submissions % of Total Submissions Fort Belvoir Fort Meade Andrews/ Annapolis 5 3.0% 1.0% Forest Glen 5 3.0% 1.0% Carlisle Barracks 4 2.4% 0.8% Fort Detrick 4 2.4% 0.8% Fort Meade 4 2.4% 0.8% Branch Total 22 13.0% 4.3% New London Groton 12 7.1% 2.3% Newport 9 5.3% 1.8% Branch Total 21 12.4% 4.1% Dover Aberdeen Proving Ground 21 12.4% 4.1% Fort Belvoir Fort Belvoir 9 5.3% 1.8% Quantico 8 4.7% 1.6% Patuxent River 3 1.8% 0.6% Branch Total 20 11.8% 3.9% McGuire/ Dix Fort Dix 20 11.8% 3.9% Fort Drum Fort Drum 20 11.8% 3.9% West Point West Point 13 7.7% 2.5% Tobyhanna 6 3.6% 1.2% Branch Total 19 11.2% 3.7% Fort Myer Fort Myer 17 10.1% 3.3% Hanscom Portsmouth 9 5.3% 1.8% District Total 169 100.0% 32.9% Fort Eustis Fort Bragg Fort Bragg 35 20.5% 6.8% Norfolk Norfolk 17 9.9% 3.3% Portsmouth 17 9.9% 3.3% Branch Total 34 19.9% 6.6% Fort Lee Fort Lee 27 15.8% 5.3% Fort Eustis Fort Eustis 26 15.2% 5.1% Camp Lejeune Camp Lejeune 25 14.6% 4.9% Cherry Point Cherry Point 24 14.0% 4.7% District Total 171 100.0% 33.3% Fort Knox Fort Knox Fort Knox 55 31.6% 10.7% Harrison Village 10 5.7% 1.9% Branch Total 65 37.4% 12.6% Great Lakes Great Lakes 38 21.8% 7.4% Rock Island 7 4.0% 1.4% Fort McCoy 16 9.2% 3.1% Branch Total 61 35.1% 11.9% WrightPatterson Selfridge ANGB 29 16.7% 5.6% Kelly Support 19 10.9% 3.7% Branch Total 48 27.6% 9.3% District Total 174 100.0% 33.9% Grand Total 514 100.0% EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM, A FOOD SAFETY SURVEILLANCE PROGRAM

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January March 2015 23 The purpose of the Destination Monitoring Program is to assess and validate producer compliance with good hygiene practices, good manufacturing practices (GMPs), and implementation of food safety risk man agement systems such as Hazard Analysis Critical Con trol Point (HACCP). Increasingly, it is recognized that preventive measures such as GMPs and HACCP are much more effective food safety management tools than end-product testing. 8,13 Some suggest that while micro bial monitoring has its place, particularly in high-risk situations like intentional botulinum toxin poisoning in milk, a better return on investment might be realized through increased funding of foodborne disease surveil lance systems. 13 However, the Destination Monitoring Program has the potential to yield important informa tion, serves as an additional level of protection against foodborne pathogens, and is used to verify safety and wholesomeness of food purchased by DoD. ACKNO W LEDGEMENT S The authors thank the AIPH-VS for providing valuable background information and perspective on the pro gram, especially COL Thomas Honadel, Dr Rebecca within the Public Health Command Region North pro vided essential background information and perspective, Analysis and Diagnostic Laboratory also provided valu Pritts and Mr Robert Leo. RE F ERENCE S 1. Painter JA, Hoekstra RM, Ayers T, et al. Attribu tion of foodborne illnesses, hospitalizations, and deaths to food commodities by using outbreak data, United States, 1998-2008. Emerg Infect Dis 2. lance for foodborne disease outbreaks Unit ed States, 1998-2008. MMWR Surveill Summ 3. Scallan E, Hoekstra RM, Angulo FJ, et al. Food borne illness acquired in the United Statesmajor pathogens. Emerg Infect Dis 4. Army Regulation 40-657: Veterinary/Medical Food Safety, Quality Assurance, and Laboratory Service 5. US Army Public Health Command. DoD Lab Sam ple Submission Guide [internet]. 2013. Available at: http://phc.amedd.army.mil/topics/labsciences/fad/ Pages/SampleSubmission.aspx. Accessed Decem ber 17, 2014. 6. Department of Defense Food Safety and Quality Assurance Laboratory Action Levels. In: USASPH Circular 40-1: Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement Aberdeen Proving Ground, MD: US Army Public Health Command: June 2014: Appen dix O. 7. Military Handbook 3006C: Guidelines for Auditing Food Establishments 8. Legan JD, Vandeven MH, Dahms S, Cole MB. De termining the concentration of microorganisms controlled by attributes sampling plans. Food Con trol. 9. Codex Alimentarius General Guidelines on Sam pling Rome Italy: Food and Agriculture Organiza 10. van Schothorst M, Zwietering MH, Ross T, Bu chanan RL, Cole MB. Relating microbiological criteria to food safety objectives and performance objectives. Food Control. 11. Dahms S. Microbial sampling plans statistical aspects. Paper presented at the 36th Symposium www.icmsf.org/pdf/032-044_Dahms.pdf. Ac cessed December 17, 2014. 12. ez N, Hoekstra RM, et al. Recipes for foodborne outbreaks: a scheme for categorizing and group ing implicated foods. Foodborne Pathog Dis 13. Institute of Medicine Forum on Microbial Threats. Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination. 14. Armed Forces Health Surveillance Center. Armed Forces Reportable Events Guidelines and Case [internet]. Available at: http://afhsc.mil/ home/reportableEvents. Accessed January 30, 2014. Table 5. Days Elapsed from Submission to Results, and Results to Product Expiration Date. Submission to Results (Days) Results to Expiration (Days) Number of food items 507 424 a Median 9 2 Minimum 1 -26.0 b Maximum 49 1801 a Data only available for food items that had an expiration date. b Negative numbers indicate that product expired prior to reporting of laboratory results.

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24 http://www.cs.amedd.army.mil/amedd_journal.aspx 15. Centers for Disease Control and Prevention. Foodborne Diseases Active Surveillance Network (FoodNet) [internet]. 2013. Available at: http://www.cdc.gov/foodnet/. Accessed January 30, 2014. 16. Centers for Disease Control and Prevention. PulseNet. 2013. Available at: http://www.cdc.gov/pulsenet/. Accessed January 30, 2014. AU T H OR S MAJ Rapp-Santos is a Laboratory Animal Medicine Resident at the US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Maryland. At the time this article was written, Dr Havas was an Epidemiologist with the Division of Integrated Surveillance at the Armed Forces Health Surveillance Center, Silver Spring, Maryland. Dr Vest is the Deputy Chief of Staff, Operations, and a Veterinary Epidemiologist at the Armed Forces Health Surveil lance Center, Silver Spring, Maryland. EVALUATION OF THE US ARMY INSTITUTE OF PUBLIC HEALTH DESTINATION MONITORING PROGRAM, A FOOD SAFETY SURVEILLANCE PROGRAM

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January March 2015 25 The US Environmental Protection Agency (EPA) was established in 1970 to protect the environment, which has the attendant effect of protecting peoples health. This correlates with one goal of the US Army Public Health Command (USAPHC): To protect Soldiers and Army communities, worldwide, from environmental conditions that could adversely af fect human health. 1 One example of an environmentally regulated process frequently used in patient care is cervical cancer screen ing. Historically, samples of cervical cells were manu ally smeared directly on a glass slide which was then sent to a lab for processing and review. This screening procedure was not reliable. Sometimes the cells were smeared too thick or too thin, commonly resulting in false positive or false negative results. In 1996, the Food and Drug Administration approved the ThinPrep Pap System (Hologic Inc, Bedford, MA) 2 which suspends the cervical cells in a methanol-based solution, then uses an automated process that places the cells uniformly on a slide. The new process has improved accuracy for cer vical cancer screening, but generates a hazardous waste (HW) in the process. Personnel ordering and using this equipment and its reagents were not initially aware this process generated a HW. Since chemical and pharma ceutical manufacturing companies are not required to communicate disposal requirements for their products, the person generating the waste must make the deter mination. In this as in most cases, the process is sim ple and personnel are available to assist. Each medical activity (MEDDAC) has personnel within the logistics and preventive medicine divisions who can assist in de termining which wastes are hazardous and which are not. Logistics and preventive medicine personnel can seek assistance, if needed, from their USAPHC regions. Determining which regulations apply can be tricky, and collaboration is often required to ensure the facilities are in compliance. There are 22 regulatory acts and 3 executive orders un der the jurisdiction of the EPA. Although all of the acts and executive orders can be applied to healthcare fa 3 and the Clean Water Act. 4 TH E RE S O U RCE CON S ERV A TION A ND RECOVERY ACT 1984. 5 According to the US Department of Agriculture, to protect human health and the environment from the potential hazards of waste disposal, to conserve energy and natural resources, to reduce the amount of waste generated, and to ensure that wastes are managed the management of solid waste (eg, garbage), hazardous waste, and underground storage tanks holding petroleum products or certain chemicals. 6 industry generating HW or storing petroleum, oils, and lubricants is regulated. Patient care, including dental and veterinary care, generates HW. Hospitals store pe troleum to power emergency generators, dining facili ties generate used oil from cooking, and facilities main tenance generates used oil during regular maintenance ly and indirectly. teristic and Listed. The Characteristic subcategories are Environmental Requirements Related to Patient Care and the Team Working to Ensure Compliance AB S TR A CT Healthcare providers are often surprised that regulations promulgated by the US Environmental Protection to harm human health and the environment, and are, therefore, regulated by federal and state environmental agencies. The importance of compliance is emphasized by the fact that both the EPA and individual state agen cies have the authority to impose civil and criminal penalties if they discover violations. The Joint Commission considers compliance important enough to include it as an element of performance in the Environment of Care standard.

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26 http://www.cs.amedd.army.mil/amedd_journal.aspx Listed categories are F, K, P and U. All HWs are Ignitable HW includes, but is not limited to, liquids containing at least 24% alcohol with a ated from cervical cancer screening becomes an ignitable HW upon disposal. The EPA HW number for ignitable HW is D001. The charac teristic of corrosive HW (D002) include liquids having a pH of 2 or lower, or 12.5 or higher. These pH ranges apply to many acids and bases HW includes wastes reactive with water, ca items that can undergo violent change without detona tion. Lithium batteries and non-empty aerosol cans are waste that can fall into this category upon disposal. The toxicity characteristic is based on the type and con ver or mercury that may be present in waste. These con stituents are harmful or fatal when ingested or absorbed; can enter the environment as leachate from improperly discarded waste; and pollute ground water. Toxicity is ity characteristic leaching procedure (TCLP). The TCLP helps identify constituents in items such as silver nitrate sticks (see illustration) that are likely to leach into the environment. Table 1 provides a list of constituents commonly found in patient care settings, with the as when reached or exceeded, makes the item a HW. processes. Examples include pressure treat ing wood or developing explosives, such as ated from these processes are HWs. This category is not applicable to patient care. The F-list consists of waste generated from processes common to multiple types of in dustrial processes. Acetone, xylene, and methylene chloride are used as solvents in paint, leather, and pesticide manufacturing, as well as by the auto in dustry for degreasing. In cases when these are used for their solvent properties, they are F-listed HW. The hos pital may not seem industrial, but xylene is used in a histology laboratory during tissue processing to dis it as an F-listed HW upon disposal. Various chemicals with solvent properties are often used in facilities main tenance, which would be the only other activity that may regularly generate this waste. The P-list and U-list consist of commercial chemical products such as formaldehyde, methanol, xylene, and warfarin (Coumadin). If such products require disposal, they will be a P or U-listed HW only when unused and if the product has only one active ingredient which is on the P or U-list. For example, an unused, expired bottle of HW because the item is an unused commercial chemical product and phenol is its sole active ingredient. In con trast, yellow fever vaccine preserved with phenol is not a U188 HW because phenol is not the sole active ingredi ent in the vaccine. Similarly, xylene used in a histology laboratory for its solvent properties would not be a U-list ed waste for disposal. However, if the xylene is expired and cannot be used, it would be managed as a U239 HW upon disposal. Table 2 lists additional items used in patient care that would be P or Ulisted HW upon disposal. The difference between the P and U-lists is that P-listed chemical products are acutely toxic. Acutely toxic refers to HW that could pose a threat to human health and the en vironment even when properly managed. Toxic HW is considered capable of posing a threat to human health and the environment in the ab sence of special handling and storage procedures. Be cause P-listed wastes are acutely toxic, the containers that hold them are also considered acutely toxic. A con tainer that held Coumadin would therefore be a P-listed HW. The same categorization applies to wrappers that contained nicotine patches and blister packs that con tained nicotine gum. ENVIRONMENTAL REQUIREMENTS RELATED TO PATIENT CARE AND THE TEAM WORKING TO ENSURE COMPLIANCE Table 1 Toxic Hazardous Waste Generated in Patient Care Constituent EPA HW Number Regulatory Level (mg/L) Sources of the Waste Stream in Healthcare Concentration Range m-Cresol D024 200.0 Insulin (m-Cresol is a preservative) 1800mg/L and up Lindane D013 0.4 Lice and scabies treatment 10,000 mg/L Mercury D002 0.2 Thimerosal preserved vaccines 200 mg/L Ophthalmic solutions 200 mg/L Amalgam Up to 400 mg/L Selenium D010 1.0 Topical or shampoo 250 mg/L and up Silver D011 5.0 Silver nitrate cauter izing sticks 200 mg/L Silver nitrate sticks

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January March 2015 27 TH E CLE A N WA TER ACT, RCR A, A ND PETROLE U M, OIL S A ND LU BRIC A NT S The majority of petroleum, oils, and lubricants (POL) as sociated with hospitals are stored in above ground stor age tanks (ASTs), underground storage tanks, or 55-gal lon drums. Fuel for emergency generators is stored in ASTs with capacities ranging from 500 to 12,000 gal lons. Used cooking oil generated in a dining facility is commonly stored in 55-gallon drums or in 400-gallon leak proof ASTs that look like dumpsters. Sites with POL storage in containers with a capacity of 112Oil Pollution Prevention which mandates a spill prevention, control, and countermeasures plan (SPCCP). The SPCCP must be updated by DPW every 5 years. Additionally, anything stored in underground storage containment system must be documented in the installa tions SPCCP. The SPCCP prescribes inspections, spill response, and spill reporting requirements. Facilities Maintenance and dining facility personnel are required to comply with the SPCCP as this document is effective ly the regulation to which the facility must comply, or be cited. In 2014, one Army installation paid $158,700 for derground storage tanks. 7 The site had 20 tanks storing gasoline, diesel, used oil, jet fuel, and anti-freeze for use in vehicles, aircraft, emergency generators, and mainte nance carts. The EPA found 19 tanks out of compliance. CHA R A CTERIZING HA Z A RDO US WAS TE S By regulation, any person or entity generating waste is required to determine if their waste is hazardous. The process commonly begins with a review of the materials safety data sheets, which provide information such as pH provided with pharmaceuticals. When a process mixes various chemicals, such as in a laboratory, a waste may require chemical analysis. This is accomplished by taking a sample of the waste laboratory for analysis. If the analysis indicates subcategories, it must be managed and discarded as a HW. The Army Institute of Public Health to assist with this process. MA N A GING HA Z A RDO US WAS TE The EPA requirements for management of HW are straightforward. At a minimum, the person generating the waste must store the waste at or near points of generation, and the storage site must be under the control of the waste generator. These storage sites are commonly called satellite accumulation points or areas. Containers at the accumulation point must be closed and marked Hazardous Waste, or with words indicating the contents. Containers must be in good condition, compatible with contents, closed when not adding or removing waste, vapor tight, and spill proof. The quantity of HW permitted at satellite accumulation points or areas is 55 gallons of nonacute HW, or 1 quart acute HW (ie, P-listed). If either limit is reached, the gen erator must remove the waste in excess of 55 gallons or 1 quart within 3 days. The waste is normally removed by the installations Directorate of Public Works (DPW) and stored at a DPW maintained facility before being sent to a HW disposal contractor. In some cases, patient care facility personnel will transfer waste to the DPW storage facilities. This is allowed only when the DPW storage facility and the patient care facility are on the same installation. Medical personnel may not transport HW off the installation or bring HW onto the installation personnel who generate HW at off-post clinics. Under most conditions, transport off the installation is allowed only by personnel who have formal permits and required if HW generated at off-post clinics is to be transported by medical facility personnel to a HW storage or dis posal facility. Transport (off post), treatment, and dispos al of HW are contracted through the Defense Logistics Agency Disposition Services (DLA-DS), formerly the As a tenant on an installation, the hospital will reim burse the DLA-DS, via DPW, for HW disposal. The conditions and costs will be outlined in an interservice support agreement between the hospital and DPW. The Table 2. Listed Category P and U Hazardous Waste Generated from Patient Care. P or U Listed Chemical EPA HW Number Trade Name Areas Where Commonly Generated Cyclophoshamide U058 Cytoxan Neosar Inpatient, outpatient, and oncological pharmacies Lindane U129 Gamen Kwell Scabene Inpatient and outpatient pharmacies Methanol U154 N/A Laboratories Mitomycin-C U010 Mutamycin Mitosol Oncology, ophthalmol ogy, and dermatology Nicotine and salts P075 Nicorette Gum Thrive Gum Nicoderm CQ Patch Nicotrol Patch Obstetrics and inpatient behavioral health Phenol U188 Physical therapy

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28 http://www.cs.amedd.army.mil/amedd_journal.aspx hospital reimburses DPW using environmental program requirement funds disbursed by the US Army Medical Command, and managed by the MEDDAC Environ ESEO is normally the Chief of Environmental Health within the Preventive Medicine Division. Although the ESEO manages the funding for disposal, Army Regula tion 40-3 8 designates Medical Logistics as responsible for the hospital waste program. Waste management pro grams are successful when the ESEO and Medical Lo gistics have a close working relationship. Each role has the support of the installation DPW, with higher level support available from the regional USAPHC. ST A TE A ND HO S T CO U NTRY REQ U IREMENT S Because our uniformed personnel move from state to state, it is important to understand that with the excep tion of Iowa, Alaska, and Hawaii, individual states have the jurisdiction to enact more stringent environmental regulations. For example, the state of Washington de dioxide from anesthetized patients, as a corrosive D002 HW. The Washington regulations require any caustic solid that causes a liquid to have a pH of 2 or lower or higher than 12.5 (when exposed to an equal volume of liquid) to be disposed of as a corrosive HW. In contrast, the EPA only regulates liquids. Pharmaceutical waste is another area where states have applied more stringent requirements or regulatory inter pretations. The DLA-DS has contracted with a pharma wanted pharmaceuticals directly from MEDDAC phar macies. The process provides credit for the pharmacy to use for future purchases, so this system is utilized Army wide. The contractor will take opened, unopened, expired, unexpired, uncontrolled, and controlled phar maceuticals from animal and patient care. The dilemma, as indicated earlier, is that some pharmaceuticals are a HW upon disposal. Colorado, Connecticut, California, Kansas, Kentucky (except for Ireland Army Community ma, South Carolina, and West Virginia will not allow a pharmacy to return expired or unusable (such as opened containers) HW pharmaceuticals through the reverse distributor. These states require HW pharmaceuticals to be managed and disposed of from the site they were deemed nonusable. We cannot forget that we have installations and bases overseas. Although host nation environmental agencies do not have the jurisdiction to impose penalties like the EPA, requirements exist overseas., In those locations where the US military is well-established, requirements are published in Final Governing Standards. These ex ist for Germany, Korea, and Kuwait, for example. Fi nal Governing Standards are a consolidation of status of forces agreements, host nation laws, and DoD Publi cation 4715.05-G 9 These differ from US requirements, lication 4715.05-G. TH E JOINT COMMI SS ION The 2014 Joint Commission EC Standard EC.01.01.01 EP1 10 requires a hospital to have a written plan for man aging the following: Hazardous Materials and Wastes. The Standard EC.02.02.01 10 requires the hospital to: maintain a written, current inventory of hazardous mate rials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those for which handling, use and storage are addressed by law and regulation. Compliance with environmental laws is required for conformance with The Joint Commission. Most hospi tals have an Environment of Care Committee, a team of personnel that performs internal audits for conformance with the Environment of Care Standard. Personnel con ducting a review of a waste management program will be successful only if they have adequate training. On many occasions, the knowledge of personnel assessing the hazardous material and waste programs is limited to hazardous material requirements of the Occupational Safety and Health Act (Pub L 91-596, 84 Stat (1970)). There are several ways to remedy this. The AIPH pro vides an online waste management course that includes training on the EPA waste management requirements as vide training to hospital personnel during assistance vis its provided for the ESEO. Local classes are often man dated by the installation. Although those classes nor mally do not cover hospital wastes and commonly focus to understand local procedures for waste management. RELEV A NT ARMY REG U L A TION S Army Regulation 200-1 11 directs compliance with envi ronmental legal mandates. Installation tenants are re quired to comply with federal, state, and local laws as well as installation policies. Army Regulation 40-61 12 assigns operational responsibil ity for waste collection and disposal to the MEDDACs chief of logistics. The ESEO acts as the principal advi sor for the waste management program per Army Regu lation 40-11 13 In most cases, the ESEO is not trained for this responsibility. Therefore, MEDCOM has tasked ENVIRONMENTAL REQUIREMENTS RELATED TO PATIENT CARE AND THE TEAM WORKING TO ENSURE COMPLIANCE

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January March 2015 29 assistance to ESEOs. Each region provides such assis tance to each MEDDAC ESEO within 6 months of the ESEOs arrival. This process is part of the framework established to help the facility avoid potential liabilities from noncompliance. INTERN A L A ND EXTERN A L IN SP ECTION S A variety of inspection programs internal to the Army, installation, or MEDDAC exists to ensure that hospitals maintain compliance. The inspections, led by MED COM assets, include the Organizational Inspection Pro gram conducted by regional medical commands, and Table 3. Civil Penalties Incurred by Federal Facilities for Violations of EPA Rules and Regulations. Agency/Installation Type Year Description Actual Penalty: Settlement Agreement Joint Army/Air Force Installation 14 2013 Failure to: conduct weekly inspections of HW facilities and containers for leakage or deterioration ensure staff participation in annual HW management training submit HW tracking reports $21,000 Air Force Base 15 2012 Improper labeling to clearly identify HW, improper management of fluorescent lamps containing mercury, and failure to: determine if a waste was hazardous have adequate training plan in place for facility workers han dling HW conduct regular inspections of HW containers $45,700: Make improvements to standard operating procedures and management controls to comply with federal hazardous waste laws. Army Installation 16 2011 Failure to: have adequate release detection with respect to piping associ ated with underground storage tanks operate an incinerator at adequate temperatures maintain adequate service records regarding appliances con taining 50 or more pounds of ozone depleting refrigerants $33,000: Agreement to purchase environmental friendly refriger ants for $310,000. VA Medical Center 17 2011 Improper disposal of hazardous waste through the biological waste system and failure to: make HW determinations inspect, label, date, and close HW containers make arrangements with emergency responders for spill response support label used oil containers $18,000: Agreement to spend $62,000 to erect an HW accumu lation building. VA Medical Center 18 2009 Unlawful shipping of HW, unpermitted on-site incineration of HW, and failure to: perform proper HW determinations properly manage HW satellite accumulation containers keep proper emergency information posted near telephones conduct weekly inspections of HW storage areas make proper advance arrangements with local fire and police departments and other emergency responders for responding to emergencies develop a proper emergency contingency plan document a personnel training plan store incompatible wastes without proper segregation $52,000: $482,000 to develop and implement a program to properly manager pharmaceutical and chemical wastes. Army Installation 19 2009 Accumulated hazardous waste in an area with a floor drain without taking measures to prevent a leak or spill, and failure to: determine whether numerous containers held HW properly label HW containers $89,500 Coast Guard 20 2008 For operating a hazardous waste storage facility without a permit or interim status and failure to label universal waste batteries. $9,280: $89,290 to purchase a new digital x-ray machine for its dental clinic. VA Hospital 21 2008 For: storage of HW without a permit open containers inadequate facility maintenance ignitable waste within 50 ft of property line failure to make a HW determination $32,500 Army Medical Center 22 1999 For improperly storing laboratory chemicals without a permit, and failure to notify the EPA prior to receiving a shipment of hazardous waste from a US Army facility in Thailand $50,400: Agreement to complete a $1.6 million project to purchase and implement a hazardous ma terial management system.

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30 http://www.cs.amedd.army.mil/amedd_journal.aspx MEDCOM Logistics and augmented by AIPH, which reviews the waste management program. The installa tions DPW Environmental Division normally has per sonnel who inspect units and tenants. Some installation DPW programs inspect weekly, others annually. Anoth er type of internal inspection is the Army Environmen tal Command Environmental Performance Assessment System (EPAS) which audits the entire installation, in cluding tenant organizations. An installation undergoes an EPAS audit every 2 to 3 years. Inspections external to the Army include EPA and state inspections. These agencies can impose notices of vio lations upon the installation that can result in civil or criminal penalties. A listing of violations resulting in civil penalties is provided in Table 3. The funds to pay these penalties do not come from the environmental funds managed by the ESEO. The penalties are paid for by the hospitals operating costs, and payment means less money for patient care. since 1998. This is comforting because in the past 3 years, Walgreens, Target, Walmart, and CVS Pharmacy, to failure to implement successful compliance programs, such as those in the Army. 23 TH E WAS TE MA N A GEMENT ASS I S T A NCE VI S IT gion personnel provide a Waste Management Assis tance Visit (WMAV). The visit introduces the ESEO to key personnel of the MEDDAC and installation en vironmental programs (MEDDAC logistics, DPW HW manager, The Joint Commission team, resource man agement), provides formal training, assists with a facil ing, coordinates waste analysis if necessary, etc. The rather than reporting them to a higher echelon, they are used as training aids to teach the ESEO to implement corrective actions based on root causes. If the root cause is systemic, AIPH will engage MEDCOM for a solution. The entire process works to help the hospital attain and maintain compliance. activity prior to the site visit which include state and lo cal regulations, and are catered to personnel. Examples ization and Management in the Laboratory, Pharmaceu of Joint Commission, and Environmental Liabilities for Commanders and Chiefs. The assistance team also ensures required waste analy sis is completed. All of this provides an effective assis tance visit that equips the ESEO to oversee the program and ensures they are introduced to the key players so they may work as a team. The program allows the ES EOs to have direct contact with the respective USAPHC a MEDDAC ESEO. Compliance is not always simple or straightforward. All parties involved fully sup port MEDCOMs efforts in the area of environmental stewardship. CONCL US ION Patient care encompasses a wide variety of processes and procedures regulated by a variety of federal, state, local, and host nation requirements. Although these re quirements are in place to ensure the health of people and their environment, they can be challenging to un derstand. The ESEO, with the help of the WMAV, is trained to assist MTF personnel to comply with these requirements. In turn, the ESEO can, at any time, con RE F ERENCE S 1. US Army Public Health Command. Environmen tal Health Portfolio [internet]. 2014. Command 2. Prep 2000 System PMA P950039. Decision Date cfm?id=6530. 3. 6901 et seq (1976). 4. Clean Water Act, 33 USC 1251 et seq (1972) 5. Hazardous and Solid Wastes Amendments of 1984, Pub L 98-616, 98 Stat 3224 (1984). 6. 7. from fuel tanks in EPA settlement [press release]. Washington, DC: US Environmental Protection vember 26, 2014. ENVIRONMENTAL REQUIREMENTS RELATED TO PATIENT CARE AND THE TEAM WORKING TO ENSURE COMPLIANCE

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January March 2015 31 8. Army Regulation 40-3: Medical, Dental, and Vet erinary Care Washington, DC: US Dept of the Army; 2013. 9. US Department of Defense. Overseas Environmen tal Baseline Guidance Document: DoD 4715.05-G Washington, DC; US Dept of Defense: 2013. 10. The Joint Commission. 2014 Comprehensive Ac creditation Manual for Hospitals Oak Brook, IL: The Joint Commission; 2014. 11. Army Regulation 200-1: Environmental Protection and Enhancement Washington, DC: US Dept of the Army; 2007. 12. Army Regulation 40-61: Medical Logistics Policies Washington, DC: US Dept of the Army; 2005. 13. Army Regulation 40-5: Preventive Medicine Wash ington, DC: US Dept of the Army; 2007. 14. for hazardous waste law violations [press release]. Washington, DC: US Environmental Protection 15. Eielson Air Force Base near Fairbanks misman aged hazardous waste and failed to maintain ad equate training plan for personnel handling waste [press release]. Washington, DC: US Environmen tal Protection Agency; March 13, 2012. Available 16. Fort Belvoir to pay civil penalty for environmen tal violations [press release]. Washington, DC: US Environmental Protection Agency; September 17. Veterans Administration Medical Center in Wich ita, Kan., to pay $17,979 civil penalty to settle haz ardous waste issues [press release]. Washington, DC: US Environmental Protection Agency; July 18. VA hospitals in Leavenworth and Topeka, Kan., agree to pay civil penalty and implement plan to manage hazardous wastes [press release]. Wash ington, DC: US Environmental Protection Agency; 26, 2014. 19. Army research facility agrees to pay penalty for hazardous waste violations [press release]. Wash ington, DC: US Environmental Protection Agency; 2014. 20. EPA and the Coast Guard settle hazardous waste violations at Portsmouth, Va. facility [press re lease]. Washington, DC: US Environmental Pro tection Agency; October 8, 2008. Available at: 21. US EPA enforcement prompts VA medical center to make changes Palo Alto Veterans Affairs Medi cal Center corrects federal environmental viola tions [press release]. Washington, DC: US Envi ronmental Protection Agency; September 9, 2008. 22. Army settles EPA complaints over waste storage lease]. Washington, DC: US Environmental Protec 35b!OpenDocument. 23. ardous waste violations. Kilpatrick Townsend Legal Alert [online serial]. June 11, 2013. Avail AU T H OR ronmental Health Engineering Division, US Army Pub McChord, Washington.

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32 http://www.cs.amedd.army.mil/amedd_journal.aspx For many years, splash pads have been constructed all over the world and are growing in popularity in the Unites States as a fun, economical way to entertain children and adults. There are an estimated 1,200 water parks in North America and about 720 in other coun tries around the world. In North America alone, water park attendance for 2012 was estimated to be approxi mately 85 million people, with an anticipated annual at tendance growth rate of 3% to 5%. 1 A splash pad is a recreational play structure that sprays treated or recycled water above the ground and is in dependently operated from another recreational water facility such as a pool. 2 Splash pads are also referred to as recreational spray parks, spraygrounds, spray pads, splash pads, spray pools, water parks, splash deck, inter active fountains, and wet decks (Figure 1). MEDIC A L CONCERN S A splash pads features equipment that is designed to through the spray feature or discharged into a wastewa ter system. A major advantage inherent in the design of splash pads is the elimination of standing water, which States, drowning is the number one cause of injury re lated death in children aged 1 to 4 years. 3 Despite the very low risk of drowning and seemingly benign nature of these parks, there remains a very real public health risk from bacteriological infections. Splash pads have the potential to become a breeding ground for communicable diseases due to 3 problems: poorly or inadequately disinfected water sources, poorly or inad equately disinfected skin contact surfaces, and poorly designed and engineered park structures. Since 1978, the Centers for Disease Control and Preven tion (CDC), the US Environmental Protection Agency, and the Council of State and Territorial Epidemiologists have maintained the Waterborne Disease and Outbreak Surveillance System (WBDOSS) for the collection of waterborne disease outbreak (WBDO) information asso ciated with recreational water activities. When a WBDO is suspected, the state and local public health depart ments are expected to investigate it and voluntarily pro vide this data to the CDC for inclusion in the WBDOSS. 1 Outbreaks at splash pads are the result of nonhygienic behaviors which contaminate the surrounding water. Pa trons ingest the contaminated water and illness can en sue if the infective dose is high enough. Common non hygienic behaviors include exposing buttocks to splash features, drinking water directly from a splash feature, Preventive Medicine Oversight of Splash Pads on Military Installations Lisa Raysby Hardcastle, PE MAJ Matthew Perry, MS, USA CPT Ashley Browne, MS, USA AB S TR A CT Over the past several years, an increasing number of military installations have installed splash pads that pro vide fun, recreational water entertainment for Soldiers and their families. The addition of splash pads brings added responsibilities for medical treatment facility preventive medicine oversight and installation facilities maintenance to ensure a safe and healthy environment. Currently, there are no consistent standards or detailed guidance for military installations to follow when installing and maintaining splash pads. The central issues associated with splash pads on military installations are water quality and risk for waterborne illnesses, re sponsibility for safety and health oversight, and federal energy and water sustainability mandates. This article examines the importance of implementing a standard for design and oversight to ensure the health and safety of Soldiers and their families. Figure 1 A typical splash pad layout.

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January March 2015 33 not showering prior to using the splash pad, and allow ing diapered children to sit in the water puddles that oth er children then intentionally or inadvertently ingest. 4 From 1995 to 2004, exposure to recreational water in the United States resulted in more than 255 WBDOs, 18,500 illnesses, and 24 deaths. Seventy-six of the 255 WBDOs were linked to treated water venues (pools, spas, hot tubs), with cryptosporidiosis being responsible for 61.8% of the illnesses. 5 During this same time pe riod, there were 6 outbreaks linked to recreational use of splash pads. Shigella infection resulted in 3 of the outbreaks, Cryptosporidium caused 2 outbreaks, and a coinfection of both Cryptosporidium and Shigella was the cause of one outbreak. Data collected from the WBDOSS from 2005 to 2006 indicated a total of 78 WBDOs, resulting in 4,412 ill nesses, 116 hospitalizations, and 5 deaths. Three-quar ters of the outbreaks (58 of the 78) occurred at treated water venues. Gastroenteritis was associated with 48 outbreaks and accounted for 4,015 of the 4,412 total re ported illnesses. Of the 48 gastrointestinal outbreaks, Cryptosporidium was associated with 31 outbreaks, and all but 2 of these outbreaks were related to treated water. 1 In 2005, the state of New York reported a massive out break associated with the use of splash pads. 6 This event resulted in more than 3,000 people reporting as ill from their exposure to the water fountain and at least 425 con Cryptosporidium hominis Although the was determined that the residual chlorine level was inad equate to inactivate Cryptosporidium in the water hold ing tanks. This outbreak likely occurred as a result of fe cal contamination of the water by an infected individual. In 2006, an outbreak of gastroenteritis was epidemio logically linked to a splash pad in Orange County, Flor ida. 5 Forty-nine individuals became ill from infections caused by Cryptosporidium (9 cases), and Giardia (38 cases). Two individuals were found to have a coinfec tion with both Cryptosporidium and Giardia Multiple breaches of proper sanitation which resulted in several the outbreak could not be determined conclusively, but is presumed to have been from asymptomatic carrier(s). In 2007, an outbreak of cryptosporidiosis occurred from a municipal splash pad in Idaho, sickening 50 people. 7 C hominis in both water sources. The initial cause of this outbreak was as sumed to be from an ill patron that frequented the park and the subsequent illnesses were due to the ingestion of the fecally contaminated splash features and drinking water. It was also determined that the 2 drinking water fountains that shared a water line with the splash pad led to the contamination of the drinking water and fur ther contributed to the number of sick people. reational water-associated disease outbreaks from 28 states and Puerto Rico. These outbreaks resulted in more than 1,326 illnesses and 62 hospitalizations. Of the 81 total outbreaks, there were 57 outbreaks associated with treated recreational water venues and 24 associated with untreated recreational water venues (lakes, oceans). Of the 57 treated water recreational water venues, 24 were caused by Cryptosporidium 8 Large outbreaks are more frequently seen in the summer months and are usually due to problems maintaining proper water qual ity, structural design, improper usage, and inadequate facility maintenance. 1 These examples demonstrate why Cryptosporidium has become the leading concern for outbreaks of gastroin testinal illness associated with disinfected recreational water venues 6 cryptosporidiosis cases each year in the United States is approximately 748,000, with an estimated annual health care cost of $45.8 million. 8 The features of Cryptosporidium that make it so menac ing are its high resistance to normal water disinfection concentrations, its small size, its low infective dose, the high number of oocysts that are shed, and the extended duration of time that they can be shed. 8 Shedding of the parasites begins at the onset of symptoms and may con tinue for weeks after the illness stops. Infection spreads by ingestion of the parasite. The incubation period av erages 2 to 10 days and the illness usually lasts 1 to 2 weeks. Although an infection can be asymptomatic (no symptoms), typical signs and symptoms of infection are stomach cramps and pain, dehydration, nausea, vomit ing, fever, weight loss, headache, joint pain, and profuse diarrhea. Young children, pregnant women, and indi of contracting cryptosporidiosis and may suffer more severe symptoms. 8 MILIT A RY REG U L A TION S A ND GU ID A NCE Technical Bulletin MED 575 2 governs splash pads on all military installations. However, it only regulates splash pads designed to recirculate water. In addition, TB MED 575 does not include guidance specifying who on an in stallation has operation and maintenance oversight of

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx Figure 2. Recreational water-associated outbreaks of gastroenteritis, by type of exposure and etiologyUnited States, 20012010. Other includes outbreaks caused by Salmonella Campylobacter Plesiomonas Sum of percentages does not total 100.0% due to rounding. 19.0% Cryptosporidium spp 15.9% Norovirus 19.0% E coli 15.9% Other 12.7% G intestinalis 3.2% Shigella spp 14.3% Etiology: Untreated Water (n=63) Cryptosporidium spp 76.2% Norovirus 4.7% E coli 2.3% Other 2.3% G intestinalis 3.5% Shigella spp 4.1% Etiology: Treated Water (n=172) Cryptosporidium spp 60.0% Norovirus 8.5% E coli 6.0% Shigella spp 6.8% Other 5.1% G intestinalis 3.4% Etiology: (N=235) Treated water 73.2% Untreated water 26.8% Type of Exposure: (N=235) splash pads. In response to these shortcomings, the doc ument is currently being updated by the US Army Pub lic Health Command. The proposed updates to TB MED 575 refer to the Model Aquatic Health Code (MAHC) 3 for information on design, construction, operation, and maintenance of recreational facilities not addressed in the current version. The MAHC was developed by CDC through a na tional partnership approach as a guidance document for state and local agencies to use as a model of public health standards for swimming pools and other aquatic facilities. However, like TB MED 575 the MAHC does not address nonrecirculating splash pads. The CDC elected to remove language regarding nonrecirculating splash pads from the draft MAHC. Based on comments received from the public, primarily through local gov ernments, the general concern with nonrecirculating splash pads appeared to be economic. 3 In addition to TB MED 575 and the MACH, military installations must comply with Executive Order 13123 9 when installing splash pads. Under that order, military installations will reduce water consumption and energy PREVENTIVE MEDICINE OVERSIGHT OF SPLASH PADS ON MILITARY INSTALLATIONS

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January March 2015 35 use throughout the installation to reach goals estab lished by the installation. Under the Armys Net Zero initiative, Army installations are focused on limiting use of freshwater resources and returning water to the same watershed in an effort to preserve the ground and surface water resources. 10 Generally, most designs for military installation build ings and facilities are based on Department of Defense ning, design, construction, sustainment, restoration, and modernization criteria. 11 Unfortunately, design, operation, and maintenance doc ated for recirculating and nonrecirculating splash pads. 11 DE S IGN RECOMMEND A TION S In order to limit the occurrence of waterborne illnesses and ensure the health and safety of Soldiers and families, military installations should follow the following design recommendations: Use the best available water source. Use and maintain the best available technology for water treatment. Consider energy and water sustainability measures. To ensure installations are using the best design rec ommendations, installation medical treatment facil ity (MTF) preventive medicine (PM) personnel should have oversight of the design of the splash pads. A study by de Man et al 12 found that higher concentra tions of E coli have been measured at splash parks using rainwater or surface water as compared to sites using potable water, independent of the routine inspection in tervals and disinfection method used. To mitigate such risk, Army installations should use potable water. Any other alternative sources of water use would be subject to applicable state law. Untreated or inadequately treated water at splash parks may allow waterborne pathogenic organisms to sur vive and infect users. Best available technology water treatment can remove and/or destroy these organisms. For example, while cryptosporidium cysts are resistant to chlorine, ultraviolet (UV) is an effective best avail able technology. Recirculating splash pads should have or cartridge), UV, and chlorination. Water treatment systems should be Underwriter Laboratories Listed and incorporate chemicals listed by NSF International (NSF)/American National Standards Institute (ANSI) Standard 60, and NSF/ANSI Standard 61 components or equipment in contact with potable water. 13,14 Nonrecir culating facilities should consider booster chlorination when the background level of free available chlorine from the public water system is not to recreational wa ter standards. Higher levels of disinfectant will sanitize the splash pad which is often used interactively by the youngest, highest at-risk population. Highly chlorinated water may require dechlorination before discharge to sanitary sewers or to a stormwater detention ponds in accordance with local and/or state governing authori ties. Not properly maintaining or using water treatment equipment in accordance with standard or standing op can result in waterborne illness outbreaks, such as the outbreaks in New York in 2005 15 and Idaho in 2007. 7 Health considerations and safety practices must be in corporated into the design during planning of a splash pad on an installation. To that end, it is important to seek advice from representatives of the installation PM staff. When feasible, planners will also include morale, welfare, and recreation representatives during concept discussions and planning charrettes. In addition to en suring that splash pad designs take into account health and safety concerns, installation planners should con sider energy and water conservation measures. 16 In accordance with multiple Army requirements, MTF PM personnel provide technical assistance and support on the requirements and methods of water conserva tion. 17 Recirculating systems use more energy at the fa cility (for booster pumping), but conserve more water overall than one-use, pass-through potable water splash parks. They also eliminate the extra energy cost of sup plying more water to a nonrecirculating system. Vari able frequency drive pumps are typically more energy as a design element, even though the initial cost may underground recycle water from recirculating systems, the installation could further conserve overall water use by collecting, storing, and pumping such water to irriga tion systems. Some states have reuse standards which Overall, when possible, all splash pads should be recir culating to conserve water in accordance with federal executive orders and water conservation mandates of DoD and the Department of the Army. BE S T MA N A GEMENT PR A CTICE RECOMMEND A TION S After design and construction, military installations should properly operate and maintain the facility, conduct baseline audits and routine inspections, and

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36 http://www.cs.amedd.army.mil/amedd_journal.aspx perform quality assurance monitoring to ensure Sol diers and families continue to enjoy splash pads with out risk of illness. The installation MTF PM personnel should continue to have oversight on splash pads after construction to ensure such best management practices are employed and health risks are minimized. The health and safety of children using splash pads de pends largely on the operation, maintenance, and inspec tion of the facility. It is important that trained personnel such as lifeguards and pool operators who are responsi ble for the water play areas understand their role in pro tecting child health and safety. The personnel respon sible for the splash pads should be trained to conduct inspections and how to handle contamination by bodily ventive medicine personnel should assess environmen tal and public health planning considerations, including but not limited to capacity (number of children allowed per square foot), daily water use, chemical requirements, seating, shade, drinking fountains, restroom and diaper changing access, foot and body showers, signage, trash receptacles, and safety and security concerns. It is important that all installation organizations involved in oversight of splash pads, including but not limited to the directorate of public works; installation safety of ing; and MTF PM personnel, have a clear understanding of inspection and maintenance program procedures and requirements, including child safety requirements in the outdoor play area. Water quality monitoring and main tenance of water treatment equipment is essential. With out clear guidance and current regulations, installations should follow the same procedures for sanitary control and operation of other recreational facilities outlined in Army Regulation 420-1 18 Technical Manual 5-662 19 and Technical Bulletin MED 575 2 Unfortunately, splash pads are not often inspected by state or local health authorities or MTF PM personnel. An inspection program is necessary to identify hazards nel should perform preopening, annual, baseline, and routine sanitary inspections on all splash pads, recircu lating and nonrecirculating, located on the installation, whether or not the state or local health authorities per form inspections. Nonrecirculated pools are typically unregulated and therefore not included in any sanitary inspection. They are also more likely to be operated by untrained personnel. Although risk for illness appears to be greatest at recirculated treated systems, safety and health issues could quickly become a rapidly es calating public health problem if personnel operating nonrecirculated splash parks do not handle incidents priately. Therefore, sanitary inspections should also in clude nonrecirculating splash parks. Further, the draft update to Technical Bulletin MED 575 2 assigns to MTF PM the responsibility to ensure state and/or local pub lic health jurisdictions are aware of and have access to privately owned water recreational facilities and/or pub lic natural swim areas. It should be reemphasized that state and local health authorities do not always come onto military installations to conduct these inspections, making it even more important that MTF PM personnel conduct the sanitary inspections on a regular basis. Children will inadvertently or intentionally drink water emitted from water features at a splash pad. Water qual ity records should be regularly reviewed by MTF PM who should also perform quality assurance sampling rep resentative of the quality of water coming from the water features, including pH, free available chlorine, presence/ absence of coliform, and heterotrophic plate count. Par ticularly in the case of recirculating systems, heterotro phic plate count monitoring can be used as a tool to opti Army regulations and guidance are currently available or being updated to address recirculating splash pads. However, there is still no regulation or guidance that addresses nonrecirculating splash pads. While nonre circulating splash pads may inherently be less of a risk for contamination, there is still a risk of contamination because individuals responsible for the facility may be untrained in sanitation practices when a contamination event occurs (ie, blood, fecal). Furthermore, nonrecircu lating splash pads, even if less costly to maintain, are not in compliance with Federal, DoD, and Department of the Army mandates to conserve water. To ensure instal lations are properly maintaining the correct operations and maintenance of already existing recirculating and nonrecirculating splash pads, there must be clear regu lation and guidance standards. The MTF PM personnel should be involved with the installation planners on the design of all splash pads and continue to maintain over sight of the splash pads during operations to ensure the health and safety of Soldiers and their families. RE F ERENCE S 1. Yoder JS, Hlavsa MC, Craun GF, et al. Surveillance for waterborne disease and outbreaks associated with recreational water use and other aquatic fa cility-associated health events-United States, 20052006. MMWR Surveill Summ 2008;57(9):1-29. Available at: http://www.cdc.gov/mmwr/preview/ mmwrhtml/ss5709a1.htm. Accessed 11/18/2014. 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January March 2015 37 2. Technical Bulletin Medical 575: Occupational and Environmental Health Recreational Water Facili ties Washington, DC: US Dept of the Army; 1993. 3. Centers for Disease Control and Prevention. Model Aquatic Health Code [internet]. August 29, 2014. Available at: http://www.cdc.gov/healthywater/ swimming/pools/mahc/structure-content/index. html. Accessed November 18, 2014. 4. Nett RJ, Toblin R, Sheehan A, Huang WT, Baugh man A, Carter K. Nonhygienic behavior, knowl edge, and attitudes among interactive splash park visitors J Environ Health 2010;73(4):8-14. 5. Eisenstein L, Bodager D, Ginzl D. Outbreak of giardiasis and cryptosporidiosis associated with a neighborhood interactive water fountain--Florida, 2006. J Environ Health 2008;71(3):18-22. 6. Yoder JS, Beach MJ. Cryptosporidiosis surveil lanceUnited States, 2003-2005. MMWR Surveill Summ 2007;56(7):1-10. Available at: http://www. cdc.gov/mmwr/preview/mmwrhtml/ss5607a1.htm. Accessed November 18, 2014. 7. Centers for Disease Control and Prevention. Out break of cryptosporidiosis associated with a splash park---Idaho, 2007. MMWR Morb Mortal Wkly Rep 2009;58(22);615-618. 8. Yoder JS, Wallace RM, Collier SA, Beach MJ, Hlavsa MC. Cryptosporidiosis surveillance-United States, 2009-2010. MMWR Morb Mortal Wkly Rep 2012;61(NSS05):1-12. 9. Executive Order 13123: Greening the Government Federal Register 109 (1999). Available at: http://www.gpo. gov/fdsys/pkg/FR-1999-06-08/pdf/99-14633.pdf. Accessed August 27, 2014. 10. US Department of the Army. Net Zero: A Force Multiplier [internet]. December 15, 2010. Available at: http://www.asaie.army.mil/Public/IE/netzero_ info.html. Accessed June 10, 2014. 11. National Institute of Building Sciences. Whole Building Design Guide [internet]. 2014. Available at: http://www.wbdg.org/ccb/browse_cat.php?c=4. Accessed September 22, 2014. 12. de Man H, Leenen EJ, van Knapen F, de Roda Hus man AM. Risk factors and monitoring for water quality to determine best management practices for splash parks. J Water Health 2014;12(3):399-403. 13. NSF/ANSI Standard 60. NSF Website. 2014. Avail able at: http://www.nsf.org/services/by-industry/ water-wastewater/water-treatment-chemicals/nsfansi-standard-60/. Accessed September 10, 2014. 14. NSF/ANSI Standard 61. NSF Website. 2014. Avail able at: http://www.nsf.org/services/by-industry/ water-wastewater/municipal-water-treatment/nsfansi-standard-61/ Accessed September 10, 2014. 15. Centers for Disease Control and Prevention. Wa ter Play Areas & Interactive Fountains [internet]. 20013. Available at: http://www.cdc.gov/healthy water/swimming/pools/water-play-areas-interac tive-fountains.html#one Accessed September 22, 2014. 16. United Facilities Criteria (UFC): Installation Master Planning Washington, DC: US Dept of Defense; 2012. UFC 2-100-01. Available at: http:// wbdg.org/ccb/DoD/UFC/ufc_2_100_01.pdf. Ac cessed September 10, 2014. 17. Department of the Army Pamphlet 40-11: Preven tive Medicine Washington, DC: US Dept of the Army; 2009. Available at: http://www.apd.army. 2014. 18. Army Regulation 420-1: Facilities Engineering: Army Facilities Management Washington, DC: US Dept of the Army; 2008 (revised 2012):264. Avail pdf. Accessed November 18, 2014. 19. Technical Manual 5-662: Swimming Pool Opera tion and Maintenance Washington, DC: US Dept of the Army; 1986:4-1. Available at: http://army pubs.army.mil/eng/DR_pubs/dr_a/pdf/tm5_662. pdf. Accessed November 18, 2014. AU T H OR S Ms Hardcastle is a Supervisory Environmental Engineer and Deputy Chief of the Environmental Health Engi neering Division, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington. MAJ Perry is Chief, Environmental Health Engineering Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington. CPT Browne is the Environmental Science Engineering Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington.

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38 http://www.cs.amedd.army.mil/amedd_journal.aspx All government-owned Army community water systems (CWSs) serving a popula tion larger than 3,300 should be optimizing directives. Existing privately-owned CWSs serving Army installations are instructed to stances allow. All future water utilities must 1,2 In the Public Health Command Region-West (PHCR-West) Area of Responsibility, shown in Figure 1, none of the CWSs serving more reports (CCRs).* However, some CCR data appear to be incomplete for CWSs practicing mum and maximum levels, nor do most include average annual value or running annual average value. Evalua tion in this article is based solely on CWSs in the PHCRWest Area of Responsibility. BA CKGRO U ND Fluoride is a naturally occurring compound derived and ocean water. Though a nonessential nutrient in the rally in almost all foods and beverages (Figure 2). It is a tasteless, odorless, and colorless element added to (cavities), although some areas in the United States and 3 Some communities in the United States and some coun last few years, Portland, Oregon, and Wichita, Kan 4,5 This past August, Is to potential health concerns. 6 There are also a number cal supplementation and dental treatments. For example, which is conceptually similar to iodized salt. 6,7 oridated water. 8 Fluoridating Army Community Water Systems in the US Army Public Health Command Region-West Area of Responsibility Lisa Raysby Hardcastle, PE CPT Ashley Browne, MS, USA 1LT Charles Pham, MS, USA Federal regulation requires public water suppliers that serve the same people year-round (community water systems) to provide con PHCD Ft Carson PHCD JBLM Region HQ District HQ PHCD San Diego PHCD San Diego PHCD Ft Carson PHCR West PHCD JBLM Figure 1

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January March 2015 39 tored daily and reported monthly to state agencies with This article BENE F IT S A ND CONCERN S factor responsible for the decline in dental caries (tooth decay) during the second half of the 20th century. The cal observation leading to epidemiologic investigation and community-based public health intervention. Al most communities, regardless of age, educational attain ment, or income level. 10 food supply chain, and bottled water can reduce caries in intentional overfeed can result in consumer overexposure (Figure 3). Additionally, according to the EPA: tures in adults, and may result in effects on bone lead ing to pain and tenderness. Children aged 8 years and an increased chance of developing pits in the tooth enam el, along with a range of cosmetic effects to teeth. 10 medical and environmental professionals, do not con form of mass medication. In 2007, the Fluoride Action ronmental professionals have signed a petition urging 11,12 nantly posteruptive (teeth after surfacing) and topical, not systemic. 13,14 cavities. 15-17 These studies challenge the proponent ben ganization, as well as many state and local public health 18-20 Figure 2 N aturally Occurring Fluoride in Water and the Environment Pesticides Containing Fluoride Food and Beve rages Including Bottle d Wate r Containing Fluoride Worker Industrial Exposure Air Fluoride Suppleme nts Toothpaste and Mouthwash Enhance d with Fluoride Dental Fluoride Tre atme nts ( Rinses, Foams and /or Re sins or Varnishe s Figure 3

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40 http://www.cs.amedd.army.mil/amedd_journal.aspx avoids $38 in dental treatment costs. 21 C WS DRINKING WA TER FL U ORID A TION REG U L A TION S lated by state and local health departments. Furthermore, water agency approval. a maximum contaminant level goal (MCLG) and a MCLGs are unenforceable health goals, based solely on enforceable standards set as close to MCLGs as con sidered feasible based on factors such as available ana lytical methods, treatment technologies, and cost. For feasibility factors pose any limitations. States, however, dards. California standards, for example, are more strin gent; the public health goal (MCLG) is 1 mg/L and the MCL is 2 mg/L. 22-24 In addition to the MCL and MCLG, the EPA has also set a secondary maximum contami nant level (SMCL) standard of 2.0 mg/L. The level of the undesirable effects of excessive exposures leading to discoloration. 4,25 The federal regulations establishing shown in Table 1. A variance in treatment may be grant ed in accordance with 40 CFR 142.61 26 if the EPA or the appropriate state authority determines the treatment ate and technically feasible for a CWS. mg/L must provide notice in accordance with the form, of 40 CFR 141.208. 30,31 In accordance with 40 CFR ter suppliers must notify their customers as soon as prac tical, but no later than 30 days after the system learns of the violation. 31,32 Fluoride in excess of 4 mg/L is a major dition to the issuance of a Tier 2 public notice in most 22-24 The regulating authority with primacy must be consult ed to determine the appropriate resolution for violations ating outside the optimal range. For example, if a water system in California operates 0.1 mg/L or more above the control range, up to 10.0 mg/L, the water supplier exceeds 10.0 mg/L, the water system must notify the the consumers, local health departments, pharmacists, dentists, and physicians in the area served by the water 33 BOTTLED WA TER FL U ORID A TION REG U L A TION S Sales of bottled water have nearly tripled in the last de cade. 34 replacing tap water, either partially or completely, as a not all do. Thus, individuals substituting a bottled water tled water does not have the same rigorous sampling and 35 This ing water regulations promulgated by the EPA, and the ter Rules. lates bottled water as a consumer beverage under the 1 Standard Fluoride Level (mg/L or ppm) Regulatory Citation Secondary MCL 2.0 40 CFR 143.3 26 MCLG 4.0 40 CFR 141.41(b) 27 MCL 4.0 40 CFR 141.62(b) 28 FLUORIDATING THE ARMYS COMMUNITY WATER SYSTEMS IN THE US ARMY PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY

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January March 2015 41 36,37 it meets all applicable federal and state standards, is sealed in a sanitary container, is intended for human consumption, and has no added ingredients except that it may optionally contain safe and suitable antimicrobial agents. 38 the label. Few bottled water brands have labels listing bottled water contains from 0.6 mg/L to 1.0 mg/L and is not for infants. lished in 21 CFR 165.110 38 and are a function of ambi pending on the annual average daily air temperatures at the location where the bottled water is sold, which again depending on the annual average daily air temper atures where the bottled water is sold. Imported bottled MILIT A RY REQ U IREMENT S F OR C WS FL U ORID A TION operating a water system that serves more than 3,300 personnel with appropriate surveillance by state and lo 2 expanded to include both existing and future privatized Technology, and Logistics) dated March 18, 2013. 1 The 40 further empha ment systems serving 3300 people or greater. Treatment systems serving fewer people will be considered on a case-by-case basis. 41 Army medical activities and US Army medical cen ride concentration to the dental activities, dental clinic commands, or dental unit commander (or designated providers, water engineers, and preventive medicine personnel. also states the condi than one-half the optimal concentration for that climate, practical and feasible. 41 42 43 and 44 nel can be found in 45 water medical oversight and technical assistance sup this guidance, when either the initiation or discontinua approval from the functional proponent for PM. Preven tive medicine responsibilities include review and recom mendations for concentration and type for any chemical Annual Average of Maximum Daily Air Temperature (F) No Fluoride Added (mg/L or ppm) Fluoride Added (mg/L or ppm) 53.7 and below 2.4 1.7 53.8-58.3 2.2 1.5 58.4-63.8 2.0 1.3 63.9-70.6 1.8 1.2 70.7-79.2 1.6 1.0 79.3-90.5 1.4 0.8

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42 http://www.cs.amedd.army.mil/amedd_journal.aspx WHA T I S OP TIM A L FL U ORID A TION? be in the range of 0.7 to 1.2 mg/L. 46 Health Organization committee suggested a level of 0.5 to 1.0 mg/L, depending on the climate. 47 In January published a proposal recommending that water systems 0.7 mg/L, as opposed to the previous temperature-de pendent optimal levels ranging from 0.7 to 1.2 mg/L. 47,48 This revision was aimed at minimizing the chance that tion that causes a discoloration of the teeth. It was also Prevention and Health Promotion that used data ranging The earlier, temperature-dependent guidance is still the standard for most states and/or local jurisdictions, as well as the Army in 50 shown in Table 3. help water systems maintain appropriate concentrations. The last revision to these guidelines was published in timum. 51 As an example, if the optimal level for a state is 0.8 mg/L, the control range would be 0.7 to 1.3 mg/L. This varies from state to state. The state of Washington, for instatnce, has established a range of 0.8 mg/L to 1.3 mg/L. 52 Therefore, the WTP operator should consult achieve effective caries prevention and to avoid measur able changes in the prevalence and severity of enamel tration as low as 0.2 mg/L. 53 dation decline as the concentration falls below optimum. As it exceeds 2.0 mg/L, there is very little additional 54 FL U ORIDE OVER F EED S overfeed events. Of the 15 total cases documented, 6 cal failure in 6 cases, electrical failure in 3 cases, and operational/installation error in the remaining 6 cases. oride poisoning in Mississippi. This event was due to reservoir. 55 trative Recommendations for Water Fluoridation have recommendations for a CWS to follow in the event of an overfeed. 51 However, state primacy regulations and that an SMCL or MCL is exceeded. One recent overfeed occurred on a military installa Annual Average of Maximum Daily Air Temperature (F) Optimum Fluoride Level (mg/L or ppm) Recommended Control Range (mg/L or ppm) 50.0 to 53.7 1.2 1.1-1.7 53.8 to 58.3 1.1 1.0-1.6 58.4 to 63.8 1.0 0.9-1.5 63.9 to 70.6 0.9 0.8-1.4 70.7 to 79.2 0.8 0.7-1.3 79.3 to 90.5 0.7 0.6-1.2 51 46,48 Annual Average of Maximum Daily Air Temperature (F) NIPDWR Recommended Control Limits Fluoride Concentrations in mg/L (maximum allowable) Low Optimum Upper Maximum Contaminant Level 50.0 to 53.7 1.1 1.2 1.3 2.4 53.8 to 58.3 1.0 1.1 1.2 2.2 58.4 to 63.8 0.9 1.0 1.1 2.0 63.9 to 70.6 0.8 0.9 1.0 1.8 70.7 to 79.2 0.7 0.8 0.9 1.6 79.3 to 90.5 0.6 0.7 0.8 1.4 Technical Bulletin MED 576 50 Technical Bulletin MED 576 FLUORIDATING THE ARMYS COMMUNITY WATER SYSTEMS IN THE US ARMY PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY

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January March 2015 43 be excessive. 56,57 period of 40 hours; the water was not declared safe to 57 According to the 2010 CCR, 58 According to JBER Air Force Bio environmental Engineering, by the operator in charge at the WTP and immediate distribution mains and individual services. 1, 2010, after a number of administrative and physical controls were implemented to correct the problem and prevent reoccurrence. FL U ORID A TION ST A T US O F CONTIG U O US UNITED ST A TE S ARMY IN S T A LL A TION S W IT H COMM U NITY WA TER SY S TEM S installations reported 58 water systems (8 within the mum range (0.7 to 1.2 mg/L or ppm), 16 water systems ridate. 60 The study reported only one day of sampling with the one exception of the Fort Bliss installation levels. 60 PHCR-West AOR. Of these 22 CWSs, only 15 CWSs (8 government-owned and 7 privately-owned) serve more levels below 0.7 mg/L, as shown in Table 5. Only 2 of these CWSs (one privately-owned and one governmentranges based on the CCRs reviewed, both of which are Based on its annual CCRs, one government-owned CWS (serving Fort Irwin, CA) continually violates the distribution systems that currently does not have a WTP senic). This installation is the only one within the PHCRprovided to military personnel and families. However, this installation has also been ordered to do so to be in A second reverse osmosis WTP is currently under con struction with a projected date to be in operation in 2016. Fluouride levels considered suboptimal according to the appear to be the most common problem in the PCHRArmy CWS annual CCRs published in 2014. In our opin ion, the method of data reporting may be problematic. One government-owned CWS (serving Fort Leonard Wood, MO) CCR indicated that only the highest mea and 2.5 mg/L in 2012, the latter of which exceeds the water program compliance manager, those were the only reported values provided by the state laboratory. Those dation of the water system. According to this installation, water and is within the operating range of 0.8 to 1.2 mg/L, the optimum being 1.0 mg/L. They also report these are typical operating levels for the WTP process, although on occasion levels can fall outside of this range. 45 A privately-owned CWS (serving Fort Leavenworth, KS) distribution system. 3 This CCR data may also not be suf One privately-owned CWS (serving JBER, AK) that ondary MCL of 2.0 mg/L in 2013 and the MCL of 4.0 mg/L in 2010, based on its CCR records. The 2010 MCL exceedance was due to an accidental overfeed of the

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx tion levels on installations di ouridation for residents on those installations. However, an even larger potentially affected popu lation may be those service per sonnel and families who do not live on military installations. in which they reside, they may dated water. For example, both CWSs serving Joint Base Lew is-McChord (JBLM) in Wash ington closely maintain optimal ever, according to Washington among the communities nearby JBLM, only the cities of Fircrest CWS in serving nearby com munities do not, including but not limited to the cities or towns Steilacoom, and Yelm where many JBLM soldiers and their families reside. 62 CONCL US ION A ND RECOMMEND A TION S F OR FU T U RE ACTION range. 60 community health dental hygienists was also recom mended to provide updates on the most current preven application would be valuable to ensure dental caregiv ride optimal standards. Memorandum of July 18, 2011 2 included the results which used CCR data, indicated that many CWSs that contrast, the 2013 CCRs reported within the PCHRprivately-owned and government-owned CWSs provid ing water to installations serving more than 3,300 peo ple. However, inconsistencies in the methodologies used by water utilities and/or installations in obtaining and of the conclusions. Installation or Facility Number of Regulated CWS 1993 Report Data 2013 CCR Data GO PO Level (mg/L) Optimally Fluoridated Range (mg/L) Optimally Fluoridated 1 1.12 Yes 0.29-0.69 1 0.63 0.2-2.08 1 0.3 reported 1 0.55 : 0.3-3.3 1.06 : 2.4-16 ( 8.75) 1 1.00 Yes -0.25 1 1 20 and 0 54 Yes 0.13-1.36 1 0.98 Yes 0.4-0.56 1 0.98 Yes 0.51-0.58 1 1.08 Yes 0.75 ( ) Yes 1 reported 0.4 ( ) 1 2 0 8 and 1 08 Yes : 0.954-1.04 : -1.30 : 0.76-0.80 2 1 10 and 1 10 Yes 0.38-1.29 and 0.4-1.4 8 7 0.3-1.20 8 11 : : 16 Yes : 2 12 1993 60 61 2013 2014 FLUORIDATING THE ARMYS COMMUNITY WATER SYSTEMS IN THE US ARMY PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY

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January March 2015 45 while those supplies above optimal levels may con considered by medical and dental personnel when pre Therefore, it is important that dental and medical per installations. Installation preventive medicine departments should encourage government-owned CWSs (via the chain of tion in annual CCRs includes the running annual aver age (RAA). If this data is not reported in the CCR, the preventive medicine department should collect this data ing. It is not necessary for preventive medicine person tem unless there are multiple treatment entry points, as disinfectants such as chlorine. copies of the latest CCRs from their local water utility or CCRs, if prepared correctly, should include the natural other organics, but should also include the operational most current published guidance, although most local and state standards still fall within the 0.6 to 1.7 mg/L range depending on the locality if still based on the am bient temperature recommendations. at JBER shows that due diligence in design, operation, and management is still important. Fluoride system design, operation, and maintenance, including water medicine water system sanitary surveys, and water/ sanitation assistance visits. State primacy agencies will The US Army Public Health Command should provide ing details in the next update to 63 of Health and Human Services recommendation for op sidered, especially for children in teething forming years. Individuals can use bottled water that is lower 64 Since consumption of bottled water has been on the rise, medical and dental personnel should consider it as regulations allow higher levels as described above. It is RE F ERENCE S 1. ogy, and Logistics. Memorandum: Fluoridation at 2014. 2. Memorandum: Fluoridation of Water Supplies 3. Water; 2014 [internet]. 2014. Available at: http:// www.waterrf.org/resources/StateOfTheScien ceReports/Fluoride_StateOfTheScience.pdf. 4. water [internet]. May 22, 2013. Avail able at: http://www.usatoday.com/story/news/na Accessed September 15, 2014. 5. dated water [internet]. news/article1102401.html. Accessed September 15, 2014. 6. August ing-water-267411. Accessed September 12, 2014.

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx 7. alternative in automatic prevention of dental caries. 2005;55(6):351-358. 8. tion/statistics/2012stats.htm. Accessed August 2014. US Environmental Protection Agency. Basic In formation about Fluoride [internet]. July 23, 2013. Accessed 10. view/mmwrhtml/mm4841a1.htm. Accessed Au 11. Statement to End Water Fluoridation [internet]. researchers/professionals-statement/. Accessed 12. 13. Washington 14. control dental caries in the United States. 2001;50(RR14):1-42. 15. 16. prevention. 17. Revelant J. Fluoride: necessary or too much of a good thing [internet]. February 24, 2013. Available at: http://www.foxnews.com/ health/2013/02/20/fluoride-necessary-or-toomuch-good-thing/. Accessed September 11, 2014. 18. American Medical Association, Statewide Fluo ridation and Fluoride Content of Municipal Wa at: http://www.ama-assn.org/ama/pub/physicianresources/clinical-practice-improvement/clinicalpage. Accessed September 11, 2014. of Public Water Supplies; Revised January 22, 2012. Available at: http://www.awwa.org/about-us/ policy-statements/policy-statement/articleid/202/ fluoridation-of-public-water-supplies.aspx. Accessed September 11, 2014. 20. Available at: http://www.who.int/water_sanitation_ pdf?ua=1, Accessed September 11, 2014. 21. at: http://www.cdc.gov/Fluoridation/pdf/natures_ way.pdf 22. Title 17 CCR Ch 15 Article 4: Primary StandardsInorganic Chemicals. July 1, 2014. Available at: ulations-2014-07-01.pdf. Accessed September 2014. 23. September 11, 2014. 24. Available at: http://www.cdph.ca.gov/programs/ Pages/FluorideandFluorides.aspx. Accessed 1 Sep tember 2014. 25. US Environmental Protection Agency. Questions and Answers on Fluoride; January 2011. Available at: http://water.epa.gov/lawsregs/rulesregs/regulat ingcontaminants/sixyearreview/upload/2011_Fluo ride_QuestionsAnswers.pdf 2014. 26. 40 CFR Ch 1 142.61: Variance from the Maximum Contaminant Level from Fluoride. July 1, 2012. Available at: http://www.gpo.gov/fdsys/granule/ CFR-2012-title40-vol24/CFR-2012-title40-vol24sec142-61/content-detail.html. Accessed Septem ber 11, 2014. 27. 40 CFR Ch 1 143.3: Secondary Maximum Con taminant Levels. July 1, 2012. Available at: http:// vol24/pdf/CFR-2013-title40-vol24-sec143-3.pdf. Accessed September 11, 2014. 28. 40 CFR Ch 1 141.51(b): Maximum Contaminant Level Goals for Inorganic Contaminants. July 1, CFR-2013-title40-vol24/pdf/CFR-2013-title40vol24-sec141-51.pdf. Accessed September 11, 2014. FLUORIDATING THE ARMYS COMMUNITY WATER SYSTEMS IN THE US ARMY PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY

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January March 2015 47 40 CFR Ch 1 141.62: Maximum Contaminant Level for Inorganic Contaminants. July 1, 2012. 2013-title40-vol24/pdf/CFR-2013-title40-vol24sec141-62.pdf. Accessed September 11, 2014. 30. ceedance of the SMCL for Fluoride. July 1, 2012. 2012-title40-vol24/pdf/CFR-2012-title40-vol24sec142-61.pdf. Accessed September 11, 2014. 31. US Environmental Protection Agency. Revised www.epa.gov/safewater/publicnotification/pdfs/ Accessed September 11, 2014. 32. 2011-title40-vol23/pdf/CFR-2011-title40-vol23sec141-203.pdf. Accessed September 11, 2014. 33. Title 17 CCR Ch 15 Article 4.1 64433.3: Moni toring and ComplianceFluoride Levels. July 1, 2014. Available at: http://www.waterboards.ca.gov/ September 2014. 34. chap2.asp. Accessed September 1, 2014. 35. Bottled Water Rules. Available at: http://www.nrdc. tember 1, 2014. 36. Water and Fluoride; July 10, 2013. Available at: ter.htm. Accessed September 11, 2014. 37. mental Protection Agency. Memorandum of Un sCollaborations/MemorandaofUnderstanding September 11, 2014. 38. 21 CFR Ch 1 165.110: Bottled Water. Revised 01 April 2014. Available at: http://www.accessdata.fda. gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?fr=1 September 11, 2014. Industry: A Food Labeling Guide (11. Appendix C: Health Claims); January 2013. Available at: http:// www.fda.gov/food/guidanceregulation/guidanced ocumentsregulatoryinformation/labelingnutrition/ 40. vember 1, 2012. Available at: http://www.wbdg.org/ tember 11, 2014. 41. Washington, 42. Army; 2013. 43. Wash 44. 45. 46. posed HHS Recommendation for Fluoride Concen Caries; January 13, 2011. Available at: https://www. federalregister.gov/articles/2011/01/13/2011-637/ proposed-hhs-recommendation-for-fluoride-con dental. Accessed September 12, 2013. 47. World Health Organization Expert Committee on Oral Health Status and Fluoride Use. Fluorides and who.int/trs/WHO_TRS_846.pdf Accessed Sep 48. ing Water: State of the Science, Regulatory Up date, and Additional Resources; 2014. Available at: http://www.waterrf.org/resources/StateOfThe ScienceReports/Fluoride_StateOfTheScience.pdf, 50.

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48 http://www.cs.amedd.army.mil/amedd_journal.aspx 51. gineering and Administrative Recommendations rr4413.pdf. Accessed September 12, 2014. 52. Available at: http://www.doh.wa.gov/Portals/1/ ber 12, 2014. 53. ing water. 54. 2003;67(5):802-806. 55. 56. chorage Military Bases. April 28, 2010. Available at: http://www.adn.com/ article/20100428/excess-fluoride-taints-water-an chorage-military-bases. Accessed September 12, 2014. 57. Available at: http://www.adn.com/node/1377831. Accessed September 12, 2014. 58. port; June 2010. Available at: http://doyonutilities. com/wp-content/uploads/docs/reports/ft_richard son/FortRichardsonJune2010CCR.pdf. Accessed September 12, 2014. Available at: http://www.jber.af.mil/news/story. 60. 2014. 61. Accessed October 28, 2014. 62. 63. 64. http:// www.nsf.org/services/by-industry/water-waste water/municipal-water-treatment/nsf-ansi-stan dard-61/ Accessed September 15, 2014. AU T H OR S Ms Hardcastle is a Supervisory Environmental Engineer Region-West, Joint Base Lewis-McChord, Washington. CPT Browne is the Environmental Science Engineering West, Joint Base Lewis-McChord, Washington. 1LT Pham is an Environmental Science Engineering Of US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington. FLUORIDATING THE ARMYS COMMUNITY WATER SYSTEMS IN THE US ARMY PUBLIC HEALTH COMMAND REGION-WEST AREA OF RESPONSIBILITY

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January March 2015 49 Tick-borne diseases (TBDs) represent some of the worlds most rapidly expanding arthropod-borne infec tious diseases. 1(p1) In the United States, ticks are respon sible for more human disease than any other arthropod group. The incidence and the number of pathogens transmitted by ticks are increasing. For example, Lyme disease is now the most commonly reported arthropodborne illness in the United States. 2 Anaplasmosis, eh rlichioses, and rickettsioses are also on the rise. 1(p1) In most parts of the world, TBDs are potentially serious health threats to troops, civilian employees, and resi dents at military installations. 2(p6) Companion animals and military working dogs (MWD)are also at risk in areas where ticks and TBDs are endemic or emerging. Risk of TBD increases with the introduction of exotic tick species into new areas and the expansion of histori cal tick ranges. One example of exotic ticks that effects the United States is Boophilus annulatus and B micro plus also known respectively as the cattle fever tick and the southern cattle tick, that were imported here by Spanish colonists who brought tick-infested cattle and horses with them. These ticks transmit a severe disease to cattle called Texas fever or cattle fever that caused enormous losses to the US cattle industry in the past. Present efforts to keep this tick out of the United States exist as the Cattle Fever Tick Eradication Program. 3 Nil gai antelopes, native to India, Nepal, and Pakistan, that were released into southern Texas are also hosts to the cattle fever ticks, posing a threat as maintenance hosts of cattle fever. 4 There are many other examples of ex otic tick introductions from migratory birds, exotic and wildlife species, and domestic animals. 5 Changes in climate may also alter the geographic distri bution of tick vectors, and in turn, cause a change in the currently recognized demographic patterns, seasonality, and incidence of TBDs. 1(p61) For example, the range of the Gulf Coast tick ( Amblyomma maculatum ) has his torically been along the Gulf of Mexico and southern Atlantic coast as far north as South Carolina, and ex tending approximately 100-150 miles inland. However, resident populations of these ticks are now established in Arkansas, Oklahoma, and Kansas, 6 and they have been collected on the east coast as far north as Delaware and Maryland. 7 Another example is the lone star tick ( A americanum ) which has moved northward as far as Maine and westward into central Texas and Oklahoma. 8 Incidental introductions of these ticks, and the diseases they carry beyond endemic regions, occur with increas ing frequency. This is likely due to the feeding of im mature ticks on migrating birds, and the transportation of tick-infested livestock and wildlife into new areas. 6 These introductions may also come from pets belonging to people who move from one area to another. In addition, suburbanization has contributed to the in crease in TBD transmission in North America by bring ing people and their pets close to ticks and by creating new tick habitat. 9 In the northeastern United States, the highest risk for Lyme disease occurs around the homes of those who have been infected. 10 As communities con tinue to expand into tick habitat, and people are encour aged to enjoy outdoor recreation and pursue activities such as urban farming, the risk for peridomestic expo sure to ticks and TBDs may increase. (NNDSS) of the Centers for Disease Control and Pre vention (CDC) maintains a list of diseases that are con sidered to be of public interest by reason of their con tagiousness, severity, or frequency. The 7 TBDs on the NNDSS list are shown in the Table. Many of these diseases, which are caused by closely re lated tick-borne pathogens, can also be acquired interna tionally. There are also many TBDs that can be acquired abroad that do not occur in the continental United States. In addition to transmitting disease, ticks can cause irrita tion, pain, and swelling at attachment sites, otoacariasis (invasion of the auditory canal), paralysis, allergic reac tions, and anaphylactic reactions. 11 Heavy infestations of ticks on animals can cause debilitation due to blood loss. Direct effects from TBDs include troop and MWD morbidity and mortality. There are also many indi rect effects, such as illness of dependents or Depart ment of Defense (DoD) civilian personnel, and related healthcare costs. Both types of effects can be mitigated through aggressive surveillance, public education, and Tick-borne Disease Surveillance MAJ Wade H. Petersen, MS, USA CPT Erik Foster, MS, USAR 1LT Beven McWilliams, MS, USA William Irwin

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50 http://www.cs.amedd.army.mil/amedd_journal.aspx prevention/control programs, together with prompt di agnosis and treatment. 2(p6) TICK BIOLOGY A ND DI S E AS E TR A N S MI SS ION Ticks are grouped into 2 separate families. Family Ixod idae, also called hard ticks, have 4 developmental stages: egg, larva, nymph, and adult. The latter 3 each take one large blood meal and then molt to the next stage, or lay eggs in the case of the adult. Hard ticks have mouthparts themselves to hosts while feeding with the assistance of a cement-like substance secreted by the salivary glands. This allows them to feed for extended periods of time that can vary from 2 to 12 days or longer, depending on species, life stage, and gender. Family Argasidae, also called soft ticks, have the same 4 developmental stages, but most have multiple nymph stages. Soft ticks have mouthparts that allow them to hold fast to their host, as hard ticks do, but they do not secrete cement. Although some soft ticks can remain attached to the host for sever al days, 11(p501) others can complete a meal within minutes to hours. 12 This is still much longer than other bloodsucking arthropods such as mosquitoes, and is one of the factors that contribute to their high vector potential because it increases the likelihood of pathogen inges tion and allows them to secrete large amounts of hostpathogens, back into the host. clude a highly sclerotized body that protects them from environmental stresses, high reproductive potential, and a long life span (compared to other blood feeding arthro pods). Although the majority of TBDs are transmitted during normal feeding activity, they can be transmit ted by other routes as well, including through regurgita tion and feces. Argasid ticks can also release pathogens through excess liquid excreted from the coxal glands legs. 11(p512) vae and nymphs are very small. The presence of an im mature tick on a host often goes unnoticed, enabling the tick to feed to repletion and drop off without detection, which increases the likelihood of pathogen transmission. Ticks can also transmit more than one pathogen at a time. For example, Ixodes ticks can simultaneously or sequentially infect their hosts with Borrelia burgdorferi Anaplasma phagocytophilum and Babesia microti 1(p61) Co-infections with these pathogens have been reported from wild and domestic animals, including dogs, as well as humans. These infections can result in more severe and longer illnesses and can complicate diagnoses. 1(p493) Ticks are also effective disease reservoirs. In some spe cies, pathogens can be transmitted from the adult female to its offspring (transovarial transmission) and from one developmental stage to the next (transstadial transmis sion). Infected ticks can also transmit viruses to uninfect ed ticks while feeding simultaneously on an uninfected host. 11(p512) Therefore, they can maintain and transmit in fections even if they have not fed on an infected host. TICK-BORNE DISEASE SURVEILLANCE Disease Agent Vector Symptoms US Region Anaplasma phagocytophilum Ixodes scapularis, I pacificus Babesiosis Babesia microti, B. divergens, B. duncani Ixodes spp Borrelia burgdorferi Ixodes scapularis, I pacificus Ehrlichiosis Ehrlichia chaffeensis, E. ewingii, E. muris-like Amblyomma americanum aches Rickettsiosis Rickettsia rickettsii, R. parkeri, R. philippi Dermacentor andersoni, D variabilis Francisella tularensis Dermacentor andersoni, D variabilis, Amblyomma americanum Disease Ixodes spp Northeastern states and the Great Lakes

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January March 2015 51 SU RVEILL A NCE Surveillance is the process of determining the presence of vectors and pests, estimating their general population levels, and determining if pathogens of concern are pres to base control and education programs and is the starting point in the prevention of any arthropod-borne disease. The analysis and interpretation of information gained from surveillance is the basis for developing quantita tive and qualitative risk assessments that can be used to predict the occurrence of pest outbreaks or vector-borne diseases. 13(p7) Various methods can be used to describe disease risk. One commonly used index is called the En tomologic Risk Index (ERI), an indicator of the number of infected ticks that a person might come into contact with over a set distance. The ERI is calculated as the number of infected ticks collected over a 1,000-meter drag (described below). Accurate ERIs are obtained by testing ticks for pathogens to determine tick infection in public education efforts and to determine if, when, and what control measures should be implemented. 13(p7) Information on vector quantity, type, and infection rates obtained from environmental sampling can be combined with human case data to help predict risk of acquiring vector-borne diseases. Ticks are active year round in some of the warmer areas of the continental United States. In fact, 31% of the ticks received at US Army Public Health Command (USAPHC) Region-West between the years 1944 and 2013 were collected in the months of November, December, January, and February. Therefore, surveillance and pathogen testing should oc cur throughout the year. SU RVEILL A NCE TY P E S Surveillance for ticks and TBDs can be accomplished both actively and passively. Public health personnel who or brush, as described in the following paragraphs, are conducting active surveillance. Passive surveillance depends on the voluntary submission of ticks to pub sis. Passive surveillance also includes the gathering of TBD data from sources such as the CDC Morbidity and Mortality Weekly Report a the USAPHC Vector-borne Disease Report b or the Armed Forces Health Surveil lance Center Medical Surveillance Monthly Report c This type of passive surveillance is important as it can give military public health personnel a rough picture of tick and pathogen presence or activity in a broad area. No single surveillance method can give a complete pic ture of TBD risk; therefore, it is important to employ as many techniques as possible. SU RVEILL A NCE MET H OD S Tick Drags Tick drags are typically constructed of a one meter square sheet of light colored, soft material, such leading edge of the material to keep it spread apart as it is pulled through the tick habitat and a two meter cord attached at both ends of the dowel can be used to pull the drag. Tick drags are conducted by passing the cloth over likely tick habitat, with the goal of collecting ticks that are questing (seeking a host). This method collects representative samples of Ixodid ticks present, and gen erally mirrors the actual exposure that a person might experience in a given area. Tick Flags is made by attaching a one meter square piece of cloth then waved back and forth under, in, and over vegetation or leaf litter, taking advantage of those areas where ticks are most likely to quest for their preferred host. Tick Walks A tick walk is accomplished by walking in a sampling area and collecting ticks that cling to the walk er. This is the best estimate of the tick threat to humans. Precautions must be taken when using this method to protect the walkers. Coveralls should be worn with tube socks pulled over the leg openings and wrist openings sealed with tape. Coveralls and socks should be white or some other light color in order to better see any ticks that may be crawling on the clothing. Traps Traps vary in design. Their basic construction consists of a collecting device that attracts ticks using carbon dioxide. Effectiveness of this method differs by species. For instance, A americanum may be collected effectively with this method. Ixodes scapularis on the other hand, are slower moving and are not effectively collected using traps. 2(p29) Wildlife Trapping and Examination Various methods are used to collect ticks from wildlife hosts. Ticks can be removed from harvested deer that are brought to check stations during hunting season. This method allows for the collection of both the tick for testing for pathogens, as well as blood and tissue from the deer. Small mam mals, including mice, chipmunks, voles, and ground squirrels are primary hosts for immature stages of ticks and can be trapped and then examined for ticks. Small mammal trapping, while labor intensive, is the most a b c

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx sensitive method to detect immature stages of ticks and to detect pathogens in host populations. Small mammal host tissues or blood samples may be collected to deter mine if pathogens are circulating in wildlife reservoirs. Nesting material can also be placed in Berlese funnels (traps used for extracting arthropods from soil and litter samples) to extract ticks. Ticks Collected at Veterinary Treatment Facilities Ticks removed from pet dogs, stray animals, and MWDs can enhance public health surveillance because they can be tested for animal and human pathogens that may circulate in the area. Pets often frequent the edges of trails or wooded areas and may come in contact with tick-infested habitats more often than people. They may, therefore, play an important role in bringing diseasetransmitting ticks into close proximity to their owners or handlers. Pets and MWDs are compliant and easily sampled. In addition to dogs, horses can be hosts to ticks that can transmit disease to humans. Clearly, surveil lance of domestic animals may assist in determining whether TBD is present. Common commercial tests, such as TickChek (TickChek LLC, East Stroudsburg, PA), Lyme-Aid (Lyme-Aid, East Stroudsburg, PA), and ProTickMe (Mainely Ticks Inc, Sanford ME), can de termine infection with several common TBDs. There is some evidence that canine tick infestation precedes the onset of human tick-related health events and could pos sibly be a useful sentinel for human diseases. 14 Moreover, owners are often motivated to have their animals tested. Most military bases have veterinary support that can co ordinate onand off-base surveillance. When dogs are brought in for examination, ticks should be collected and pathogen testing. This type of surveillance can be facilitated through the use of preconstructed submission kits. The kits include instructions on how to submit a tick, a collection container (such as a plastic vial), a stan dardized submission form, and a preaddressed padded envelope for shipment. Ticks Collected From People Ticks removed from peo ple can be sent to the USAPHC Army Institute of Pub lic Health Entomological Sciences Program through the DoD Human Tick Test Kit Program, which is a free tick cilities. More information can be found at the Human Tick Test Kit Program web site.* Care should be taken to remove ticks promptly and properly to prevent infec tion with TBD, to ensure mouthparts are not left in the proper methods to remove ticks are listed in the inset. IM P ORT A NCE The geographic ranges of many tick species are expand ing, and the serious diseases transmitted by ticks are becoming more common. 15 Due to overlapping tick and host ranges, this expansion may also lead to more co-in fections and areas with multiple pathogens and vectors. As previously discussed, co-infections are not unusual and can result in more severe illness than infection with a single pathogen. 1(p243) In the United States alone, TBDs produce tens of thousands of illnesses every year, many of which are severe and result in hospitalization, longterm illness, disability, and death. 1(p155) Tick surveillance is the starting point for effective TBD prevention. Surveillance establishes species and densi ties of tick populations present in a given area, and pro vides data for establishing the potential TBD risk. This data provides leaders, preventive medicine personnel, pest management professionals, and individuals the in formation they require to promote proactive measures, including behavior change such as using personal pro tective measures and avoiding tick habitat, and tick-tar geted strategies (tick checks or tick population reduction measures) 1(p155) to prevent TBDs. Tick surveillance will be most effective when multiple entities are involved. The USAPHC personnel can visit installations and collect ticks. Given the limited scope of assess the risk of TBDs. Limited budgets also make this a less than cost-effective way to address TBDs. Local entities, most notably from installation preventive medi cine and veterinary personnel, should make efforts to augment the work currently performed by USAPHC personnel. For example, Public health Command Re gion-West (PHCR-W) personnel collected ticks from 8 installations during 2014 while only 2 installations TICK-BORNE DISEASE SURVEILLANCE Proper Tick Removal Do: Do Not:

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January March 2015 53 the installations within our 20-state region would col lect and send ticks for analysis, the knowledge of TBD risk in the region would be greatly improved. Analysis of TBDs should be expanded to include all tick species that are considered vectors as well as the pathogens they transmit because the epidemiology of newly emerging TBDs is not well known. For example, Rickettsia 364D 16 Illness caused by this pathogen is now a reportable dis ease under the California Code of Regulations Title 17. 17 It is also listed on the CDC web site as a source of Rick ettsial infections. 10 Because R rickettsii (the causative agent of Rocky Mountain spotted fever) is rarely identi that Rickettsia 364D, provisionally named Rickettsia phillipi is responsible for many of the illnesses in this region that resemble and are misdiagnosed as Rocky Mountain spotted fever. 18(p671) Dermacentor occidentalis Rickettsia 346D and occurs throughout California and in parts of Oregon. Both immature and adult stages of this tick are relatively indiscriminant feeders and will readily bite humans. 19 Rickettsia 364D has been detected in up to 11% of D occidentalis from 8 California counties. 16(p542) Without diligent surveillance and pathogen testing, changes in tick distributions and the risk of acquiring TBDs will remain unknown, especially for newly emerging TBDs. Two other recent examples of newly described, emerg ing TBDs include Heartland virus 20 and Ehrlichia murislike infection. The Ehrlichia muris-like organism was isolated from I scapularis ticks during an outbreak in vestigation in Wisconsin in 2009. 21 Previously, only Eh rlichia chaffeensis and E ewingii were thought to cause tick-borne Ehrlichiosis in humans in the US, and neither is endemic in Wisconsin or Minnesota. When patients in these states, without travel to endemic areas of the United States, began to present to their healthcare pro viders with symptoms of Ehrlichiosis and were further investigated, blood samples submitted for polymerase undescribed Ehrlichia species. Field surveys and retro spective testing of I scapularis ticks further established that Ehrlichia muris-like is present in tick and wildlife populations. 22,23 associated with human infection described in the United States. 24 Two hospitalized patients with a history of ex posure to lone star ticks, A americanum presented to hospitals in northwestern Missouri in June 2009. Both patients, males over 55 years-old, presented with fever, fatigue, anorexia, nausea, low white-blood-cell count, low platelet count, and elevated liver enzymes. The pa tients were thought to have Ehrlichiosis, but failed to improve upon treatment with antibiotics. Further blood tests including PCR, sequencing, and electron microsco cally similar to the severe fever with thrombocytopenia syndrome virus. In 2012, ticks were collected from 12 sites including both patients farms, and infection rates in A americanum nymphs were found to range from 0.47 to 3.91 infected ticks per 1,000 throughout the tick sea son. These examples highlight the importance of TBD surveillance as the collaboration between the medical, laboratory, and public health entomology communities led to the discovery early in the course of disease emer gence of both of these pathogens. Public Health Command Region-West conducts surveil lance and testing for military installations in the western region of the United States including Missouri, Minne mental agency to detect Lyme disease from ticks or ro dent biopsies in Santa Barbara and San Louis Obispo County, California. Once the detection techniques for Lyme disease were perfected, PHCR-W expanded its ca pabilities to test ticks and rodent tissue for other TBDs to include Ehrlichia chaffeensis, Anaplasma phagocyto philum and Spotted Fever group Rickettsias We have since detected Ehrlichia from 4 installations in Missouri and A phagocytophilum in Minnesota and California. Several Rickettsia rickettsia and Ehrlichia chaffeensis tick pools were detected among ticks from dogs at Fort Leonard Wood, Missouri, in 2011. These surveillance activities have led to installation awareness and TBD risk assessments at numerous installations. and leaders prior to training operations in tick habitat to increase awareness and personal protective measures needed to minimize the transmission of TBDs. The surveillance activities initiated by PHCR-W have also detected ticks transported on pets from other areas of the world, including German ticks on MWDs arriv ing at Joint Base Lewis-McCord (JBLM) and Beale Air force Base, an African tick off a tortoise in Washington state, a Missouri tick off of a MWD to JBLM, and a tick from the state of Georgia transported to Arizona during a PCS move. These examples highlight the importance of maintaining active surveillance and expanding tick testing capabilities for newly emerging TBD pathogens.

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx Equally important to increasing laboratory capabilities for the detection of TBDs is the assurance of reason able but quick turnaround times for laboratory results. The public health value of any information gained from laboratory tests diminishes quickly over time. Further, customers who receive reports weeks or months after submitting specimens will be less likely to continue to make the effort to collect and send ticks to public health entities. Promptly detecting pathogens in submitted ticks is important in making determinations of the risk of TBD in military personnel, dependents, companion animals, and MWDs. It is also crucial in the planning and timing of disease control efforts, including vector control and educational activities. Public Health Com mand Region-West provides TBD laboratory analysis collection data (species, site, collection date), laboratory mendations on continued surveillance. The prevention of TBDs is based on personal protective measures, landscape and environmental measures, and preventive treatments to ensure that infected ticks do not bite people or animals.The determination of disease risk and the employment of environmentally and eco nomically sound tick control methods effectively result from TBD surveillance. Possibly of even greater impor tance, information acquired through tick surveillance can bolster public education and improve the awareness and health literacy of the military community regarding TBDs. Properly informed and aware personnel make more intelligent decisions about activities that put them at risk of TBD exposure and the personal protective measures that can be taken to reduce that risk. Clinical, preventive medicine, veterinary, pest management, and Army Public Health Command personnel must work co operatively to improve the knowledge of tick species dis tributions and the incidence of the diseases they trans mit. Liaisons with these entities and with state and local public health departments should also be established. CONCL US ION Ticks are one of the major vectors of disease that threat ens military personnel, families, and civilian employ ees on US military installations. 25 The presence of tickborne disease in military personnel, including our mili tary working animals, may result in the loss of training days, decreased force strength, and may adversely af fect unit readiness and effectiveness. Tick-borne disease also affects DoD civilians and the families of our troops. Soldier and unit readiness may be affected when fam ily members and companion animals are sickened by TBDs. The information gained from tick surveillance regarding tick vectors, disease incidence, and pathogen prevalence is invaluable. It allows medical personnel to educate personnel regarding tick-bite and TBD recogni tion and prevention. Tick surveillance information also enables leaders to make decisions regarding the appli cation of safety and control measures during training and operations to prevent TBDs. As with any disease, prevention of TBDs is highly preferable to treating the shortand long-term consequences once they occur. 1(p155) RE F ERENCE S 1. Institute of Medicine. Critical Needs and Gaps in Understanding Prevention, Amelioration, and Res olution of Lyme and Other Tick-Borne Diseases: The Short-Term and Long-Term Outcomes: Work shop Report Washington, DC: Washington, DC: The National Academies Press; 2011. Available at: http://www.nap.edu/catalog/13134/critical-needsand-gaps-in-understanding-prevention-ameliora tion-and-resolution-of-lyme-and-other-tickbornediseases. Accessed December 1, 2014. 2. Armed Forces Pest Management Board Technical Guide No. 26. Tick-borne Diseases: Vector Sur veillance and Control Silver Spring, MD: Armed Forces Pest Management Board Information Ser vices Division; 2012. Available at: http://www.af pmb.org/sites/default/files/pubs/techguides/tg26. pdf. Accessed December 1, 2014. 3. Animal and Plant Health Inspection Service; Vet erinary Services. Controlling Cattle Fever Ticks Factsheet. Washington, DC: US Department of Agriculture; August 2010. Available at: http://www. aphis.usda.gov/publications/animal_health/con tent/printable_version/cattle_fever_ticks.pdf. Ac cessed December 1, 2014. 4. Moczygemba J, Hewitt D, Campbell T, et al. Home ranges of the Nilgai antelope (Boselaphus trago camelus) in Texas. Southwest Nat. 2012;57(1):26-30. 5. spread and distribution of ticks. In: Salman M, Tarrs-Call J, eds. Ticks and Tick-borne Diseases: Geographical Distribution and Control Strategies in the Euro-Asia Region Boston, MA: CABI Pub lishing; 2013;27-32. 6. The TickApp for Texas & the Southern Region: Gulf Coast tick [internet]. The Texas A&M Univer sity System Web site; 2011. Available at: http://tick app.tamu.edu/ticks/gulfcoasttick.php. Accessed August 29, 2014. 7. Florin D, Brinkerhoff R, Gaff H, et al. Additional US collections of the Gulf Coast tick, Amblyom ma maculatum (Acari: Ixodidae), from the State adult specimens from the State of Maryland, and data regarding this tick from surveillance of mi gratory songbirds in Maryland. Syst Appl Acarol 2014;19(3):257-262. TICK-BORNE DISEASE SURVEILLANCE

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January March 2015 55 8. Centers for Disease Control and Prevention. Lone star tick a concern, but not for Lyme disease [inter net]. October 21, 2011. Available at: http://www.cdc. gov/stari/disease/. Accessed September 17, 2014. 9. Ginsberg H, Faulde M. Ticks. In: Bonnefoy X, Kampen H, Sweeney K, eds. Public Health Sig Copenhagen, Denmark: 10. Connally NP, Durante AJ, Yousey-Hindes KM, Meek JI, Nelson RS, Heimer R. Peridomestic Lyme disease prevention: results of a popula tion-based case control study. Am J Prev Med 2009;37(3)201-206. 11. Nicholson WL, Sonenshine DE, Lane RS, Uilen berg G. Ticks (Ixodidae). In: Mullen G, Durden L, eds. Medical and Veterinary Entomology 2nd ed. London, UK: Academic Press; 2009:483-532. 12. Sonenshine DE, Anderson JM. Mouthparts and digestive system: anatomy and molecular biology of feeding and digestion. In: Sonenshine DE, Roe RM, eds. Biology of Ticks 2nd ed. New York, NY: Oxford University Press; 2014;122-162. 13. United States Air Force Guide to Operational Surveillance of Medically Important Vectors and Pests-Operational Entomology Ver 2.1. Washing ton, DC: Dept of the Air Force; August 15, 2006. Ver. 2.1. Available at: http://www.afpmb.org/sites/ guide.pdf. Accessed December 2, 2014. 14. Glickman L, Rhea S, Glickman S, Waller A, Ising A, Engel J. Canine tick diagnoses are a sentinel for tick-borne diseases in people. Adv Dis Surveill. 2008;5:176. 15. McKenna M. The advance of ticks: new areas, new diseases, and a weird allergy to meat [internet]. Wired Science Blogs December 28, 2012. Available at: http://www.wired.com/wiredscience/2012/12/ ticks-new-meat/. Accessed August 30, 2014. 16. Shapiro M, Fritz C, Tait K, et al. Rickettsia 364D: a newly recognized cause of eschar-associated illness in California. Clin Infect Dis 2010;50(4):541-548. 17. California Department of Public Health. Labora tory testing for spotted fever rickettsiosis. Rich mond, CA: Viral and Rickettsial Disease Labora tory Branch/Division of Communicable Disease Control. July 2012. Available at: http://www.cdph. ca.gov/programs/vrdl/Documents/VRDLTesting forSpottedFeverGroupRickettsia_FINAL.pdf. Ac cessed December 1, 2014. 18. Parola P, Paddock CD, Socolovschi C, et al. Up date on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev 2013;26(4):65702. 19. Mediannikov O, Paddock CD, Parola P. Other rick ettsiae of possible undetermined pathogenicity. In: Raoult D, Parola P, eds. Rickettsial Diseases 1st ed. New York, NY: Informa Healthcare; 2007:163-177. 20. Savage HM, Godsey MS Jr, Lambert A, et al. First detection of heartland virus (Bunyaviridae: Am J Trop Med Hyg. 2013;89(3):445-452. 21. Pritt BS, Sloan LM, Johnson DK, et al. Emer gence of a new pathogenic Ehrlichia species, Wisconsin and Minnesota, 2009. N Engl J Med 2011;365(5):422-429. 22. Stromdahl E, Hamer S, Jenkins S, et al. Compari son of phenology and pathogen prevalence, includ ing infection with the Ehrlichia muris-like (EML) agent, of Ixodes scapularis removed from soldiers in the midwestern and the northeastern United States over a 15 year period (1997-2012). Parasit Vectors 2014;7(1):553 (Epub ahead of print). 23. Castillo CG, Eremeeva ME, Paskewitz SM, et al. Detection of human pathogenic Ehrlichia murislike agent in Peromyscus leucopus. Ticks Tick Borne Dis In press. 24. McMullan LK, Folk SM, Kelly AJ, et al. A new phlebovirus associated with severe febrile illness in Missouri. N Engl J Med. 2012;367(9):834-841. 25. Beard CB, Strickman D, eds. Federal Initiative: Tick-borne Disease Integrated Pest Management White Paper. Washington, DC: Federal Tick-Borne Disease Integrated Pest Management Workgroup; 2014. Available at: http://www.epa.gov/pestwise/ ticks/tick-ipm-whitepaper.pdf. Accessed Decem ber 1, 2014. AU T H OR S Division, US Army Public Health Command RegionWest, Joint Base Lewis-McChord, Washington. CPT Foster is assigned to the Entomological Sciences Program, US Army Public Health Command RegionSouth, Joint Base San Antonio Fort Sam Houston, Texas. Sciences Program, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington. Mr Irwin is assigned to the Entomological Sciences Pro gram, US Army Public Health Command Region-West, Joint Base Lewis-McChord, Washington.

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56 http://www.cs.amedd.army.mil/amedd_journal.aspx Many recent veterinary school graduates will recall 2 pieces of advice; when you hear hoof beats, think hors es, not zebras, and the simplest explanation is usually are crucial to keeping providers differential diagnosis list concise and making sure it is prioritized correctly. When teaching new veterinary or medical students, it is logical that one should not spend as much time on diseases that they are less likely to see in practice. For Northwest may only learn about Salmon Poisoning Dis ease (SPD) in the theoretical sense as they may never see a case during their studies, let alone treat a patient while in school. SPD is a disease caused by the bacte rium Neorickettsia helmintheoca which is carried by Nanophyetus salminocola most classically in salmon, which is why the disease is students in that area will be far more likely to see and treat the disease while in school than their colleagues in other locations. It causes a sudden onset of vomiting, diarrhea, decreased appetite and lethargy, and is often fatal without appropriate treatment. 1 The importance of this geographic bias is illustrated by the experiences of spayed Labrador presenting for vomiting, diarrhea, and considered the typical differentials; foreign body, gas troenteritis, infectious causes, nongastrointestinal signs, but did not consider SPD as she went to school in another area and was thus unfamiliar with the disease. Luckily a treated successfully. This example serves as a reminder to clinicians that geographical bias can preclude the cor rect diagnosis. biases when seeing patients. Due to the international and mobile nature of the Department of Defense and its members, these geographic zebras are even more likely to walk into our exam rooms. Recognizing and addressing these biases is important, not only for treat ing the individual patient but also for general public health. Many of the diseases discussed below are com municable and potentially zoonotic. When we are ask ing questions about a pets history and performing our physical exam, we must recognize our own biases and remind ourselves to use a problem-oriented approach to our patients. In doing so, we can remind ourselves that while those biases might be valid in certain situations, they may hinder an accurate diagnosis in another. Fur thermore, we must consider diseases that are endemic in the patients previous geographic location or areas to which the pet may have traveled. Remembering our bi ases and considering travel will help practitioners man age their differential diagnosis list. RECOGNIZING BI AS A ND UNCOVERING ZEBR AS As explained above, certain diseases are not discussed in detail at veterinary schools in different geographi cal locations because they are absent or have a very low prevalence which may lead to a basic geographical bias preventing us from considering different causative agents. Veterinary clinicians may leave certain diseases off of their differential diagnosis list because they have not considered travel (whether international or within the United States). This travel may be by the presenting animal, disease vectors, owners, or other domestic and wild animals with which the patient had contact. Failure to account for this geographic bias may result in numer ous diseases not considered, although those diseases could be the cause of the patients clinical signs. national movement of humans and animals from areas with different endemic diseases. For example, rabies has been around for thousands of years and has great on differential diagnoses lists for neurologic canine pa tients within the United States. International travel al lows rabies to enter new geographic regions, and should make it mandatory to include on the differential diagno sis list for any animal with neurologic symptoms. The canine rabies virus variant, associated with dog-to-dog Managing Your Differential Diagnosis List: Considering Bias and Recognizing Unexpected Infectious Agents CPT Lauren Seal, VC, USA CPT Aimee Hunter, VC, USA

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January March 2015 57 transmission, is most often responsible for the estimated 55,000 human rabies virus deaths worldwide each year. 2 United States in 1950. That number was down to 79 in 2006, when the canine rabies virus variant was declared eradicated in the United States. Today, rabies is well controlled in the United States due to effective and read ily available vaccines along with stray animal control. Consequently, when presented with a neurologic case in the United States, many clinicians may not initially con sider rabies as a possible differential. However, recent events have served as reminder to the military impor tance of rabies. This disease is enzootic in the Middle East where many of our Soldiers deploy. Unfortunately, Soldiers may not understand why they are not allowed to keep stray dogs as pets; the stray dog may remind them of home, and they are often very resentful when these pets are removed. In fact, there are several or ganizations who are dedicated to bringing these stray dogs from the Middle East to the United States, and other countries, to be reunited with the Soldiers. This action has directly resulted in at least one case of a ra bid dog being imported into the United States, and the exposure of numerous American citizens to the deadly rabies virus. 4 The act of keeping pets while deployed, although against policy, has also resulted in the unfortu nate and unnecessary death of a Soldier from rabies and countless others receiving postexposure prophylaxis; a treatment which can be both painful and expensive. 5 It medical providers to understand the prevalence of ra bies and other endemic diseases where our Soldiers de ploy, when considering differential diagnoses. This is also a concern for civilian veterinarians as they are even less likely to include foreign diseases such as rabies on a differential list, but it is possible for them to see a dog adopted from an area where those diseases are endemic. Rabies is a real possibility, even in the United States, when you consider the mobility of our population and the possibility of international travel. far more likely within the United States, but are still often overlooked due to localized geographical loca tion. Lyme disease, for example, is caused by Borrelia burgdoferi a bacterium carried by the Ixodes tick, the most common in the United States being I scapularis and Previously, Lyme disease has had a few endemic areas of the United States, most commonly in the northeast (by far the most common location), while also being reported with some frequency in Wisconsin, 6 Recent surveillance data indicates that Lyme disease is increasing in terms of reported cases, as shown in the Table. 7 A review of Centers for Disease Control and Prevention data clearly shows an expansion (illustrated in the Figure) of Lyme from those previously endemic areas to many cases in previously unaffected states as it is now present in all disease has spread for a variety of reasons including temperature, moisture, forest cover, and population den sity. All of these factors were used by the Companion Animal Parasite Council to predict the spread of Lyme disease occurrence within the United States. 8 Lyme disease can present with numerous signs including fe ver, lameness, anorexia, lethargy, and lymphadenopa thy, and may or may not present with swollen joints. 1 These general signs can make the disease somewhat study evaluated the potential predictive value of canine seroprevalence as it relates to human cases of Lyme dis ease in a given county. The study found that there was correlation between canine seroprevalence and human than 5% of dogs was associated with human Lyme in cidences that were above averagethe median number of human cases increased by more than 20 individuals (compared to a canine seroprevalence of 1.1% to 5%). 9 However, a much earlier study (1991) 10 was not able to prove the same association between canine and human cases. (It is important to note that the studies were per formed 10 years apart and on different continents, so it is possible that the predictive value of canine Lyme cases is very location-dependent.) However, the earlier study still concluded that canines are good sentinels for human cases, given that they are much more likely to come in contact with the tick vector. They are, therefore, more likely to be infected early after the vector enters their geographic location. Chagas disease is another example of a diagnosis that can be missed due to geographical bias, and, according to the due to the movement of people from Latin American to other locations around the world. 11 It is a parasitic disease caused by Trypanosoma cruzi that initially presents with fever, lymphadenopathy, and hepatosplenomegaly, along with other general symptoms. 7 The protozoa are spread by the Reduviidae or triatomine (kissing bug). Among humans, Chagas disease is the most common cause of congestive heart failure in the world. 12 Within endemic areas, the disease has moved from the more rural areas into cities via human migration. The infection has also been shown to spread into many southern states in the United States from Georgia to California because of the high population of animals involved in the protozoas life cycle: raccoons, opossums and canines. It is also

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx important to remember that eleven different species of cies in the Americas, many of which can be infected by and transmit T cruzi . 14 This is particularly concerning given the risk of long-term carriers with Chagas disease. Studies have proven that a chronic phase of infection is possible in humans and they can serve as reservoirs for subsequent T cruzi infections. 15 It is theorized that chronically infected canines may also serve as poten tial reservoirs for canine and human disease transmis sion. 16 The US Department of Defense trains all of its military working dogs (MWDs) at Lackland Air Force endemic. These MWDs are potentially exposed to Cha gas disease during training, and could serve as poten tial reservoirs for disease transmission at their new duty site, particularly if the MWDs are asymptomatic prior to their permanent change of station move. Multiple dogs for Chagas antibody, and at least one MWD has died of the myocardial effects of the disease (unpublished data, Department of Defense Military Working Dog Hospital, consider Chagas as a diagnosis. New or emerging diseases in certain areas of the world are also concerning given human animal and human travel. Leishmaniasis is endemic in several regions throughout the world including locations where US mil itary personnel and animals are stationed (eg, Middle East, southern Europe). 15 A case of canine leishmani McChord Veterinary Center in Washington state. The patient was a 2-year-old male mixed-breed dog who initially presented to a civilian veterinarian for inability to gain weight, lethargy, and decreased appetite. A thor ough history revealed that the dog was adopted from Af ghanistan. Unfortunately, no records were available as to whether the dog received a health examination by an accredited veterinarian prior to travel or whether he was healthy and free of disease at that time, though the adop tion agency stated that animals are free of clinical signs prior to entry into the United States. He was started on antibiotics, but because he showed no improvement, the clinic for a second opinion. At the second presentation, he had persistent weight loss in addition to 2 mm to 5 mm white nodules around his eyes and on his muzzle. These nodules were aspirated and contents examined under microscopy where it was revealed that they con tained the protozoon that causes leishmaniasis, which is an obligate intracellular parasite. The patient was started on oral medications based on case reports us ing the medications available. Later, the client opted to move to a civilian clinic and at last follow-up was doing very well, gaining weight, increased energy, and ownerperceived less pain. Geographic distribution of cases of Lyme disease reported in the United States in 2001 and 2013 respectively One dot is tion ( 2013 2001 2001 through 2013 Year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 Total Reported Cases 17,029 23,763 21,273 19,804 23,305 19,931 27,444 28,921 29,959 22,561 24,364 22,014 27,203 MANAGING YOUR DIFFERENTIAL DIAGNOSIS LIST: CONSIDERING BIAS AND RECOGNIZING UNEXPECTED INFECTIOUS AGENTS

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January March 2015 59 As previously mentioned, leishmaniasis is a disease of military importance; more than 600 soldiers have been diagnosed with the cutaneous form of the disease af ter deployments to Iraq, Kuwait, and Afghanistan. 17 Clearly, human and animal travel is playing a role in the expanding distribution of leishmaniasis cases at di agnosis. Leishmaniasis is a disease caused by the pro tozoa, Leishmania 1 Numerous different species of the protozoa have been known to cause infection including L major and L trop ica which tend to cause the cutaneous form, and L in fantum and L donovani which cause the visceral form. 15 This has typically only been found in areas where the explained that dogs can spread the disease sexually or transplacentally. 18 Additionally, while direct zoonotic transmission is believed to be a rare occurrence, 19 there Lutzomyia ) within the United States. 20 While a competent vector has not less theoretically possible. All of these issues mean that leishmaniasis has potential to become an issue for both veterinary and human medicine in the United States, which could pose challenges for clinicians in diagnosis and successful treatment, especially considering that medications for treatment are not readily available in the United States. Late diagnosis could therefore be cat astrophic for a patient in that treatment could be delayed MA N A GEMENT O F DI FF ERENTI A L LI S T S How does the clinician manage a differential diagnosis list when theoretical possibilities are almost endless? The most important management tool is a thorough his tory. It is crucial that the clinician determines any travel history, human or animal, since all diseases discussed here are a concern for both human and animal health, and most are zoonotic. Another possibility is to recom mend preventive measures for disease even when not in an area considered endemic. For example, should mili tary veterinarians recommend a Lyme disease vaccine to all patients, even in those areas where Lyme is not considered endemic? In addition, clinicians must con sider diagnostics, such as the bloodwork, imaging, or cytology that may help to diagnose a disease that may not even be on their differential list. This means con sidering tests that give enough information to direct later diagnostics and remembering to use the problemoriented approach. Even basic tests such as in-house cy tology can be crucial in identifying certain infectious as well as other clinicians must maintain an open line of communication, meaning that we need to discuss cases, write case-reports, and otherwise keep our colleagues informed of new diseases within a geographic location. This will help our colleagues keep these zebras in mind. IN SU MM A RY Every day, providers must manage cases based on the most likely explanation for the information presented. all of the needed information is attained. We are con stantly biased by various factors as clinicians, including geographic location (as the examples above illustrate). Providers must ensure that these zebras, and others like them, are always kept on our differential diagnosis list. It is also crucial to ensure that the historical infor mation is complete and the physical exam is thorough. In truth, rabies virus must also be on the differential for a dog with unknown vaccination history with neurolog ic symptoms, and SPD should be on the list for any dog that is vomiting. How far up we rank them on the list of differential diagnoses depends on how thoroughly we conduct our patient histories and account for potential to reach the correct diagnoses in time to implement ap propriate treatment. RE F ERENCE S 1. Kahn CM, Line S, eds. The Merck Veterinary Man ual 2005. 2. surveillance in United States during 2006. J Am Vet Med Assoc. 4. Centers for Disease Control and Prevention MMWR Morb Mortal Wkly Rep 5. Centers for Disease Control and Prevention Imported human rabies in a US Army Soldier New York, 2011. MMWR Morb Mortal Wkly Rep 6. Heymann DL, ed. Control of Communicable Dis eases Manual 18th ed. Washington, DC: American Public Health Association; 2004. 7. Centers for Disease Control and Prevention. Lyme Disease [internet]. Available at: http://www.cdc. gov/lyme/stats/maps/interactiveMaps.html. Ac

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60 http://www.cs.amedd.army.mil/amedd_journal.aspx 8. expanding its range westward in 2014 [internet]. Companion Animal Parasite Council Web site; 2014. Available at: http://www.capcvet.org/expertarticles/lyme-disease-is-expanding-its-range-west 9. Mead P, Goel R, Kugeler K. Canine serology as ad junct to human Lyme disease surveillance. Emerg Infect Dis 2011;17(9):1710-1712. 10. Dogs as sentinels for Lyme disease in Massachu setts. Am J Public Health 1991;81(11):1448-1455. 11. ganization Web site; 2014. Available at: http://www. 12. panosomiasis) in North America. Vet Clin North Am Small Anim Pract panosoma cruzi and Chagas Disease in the United States. Clin. Microbiol. Rev 2011;24(4):655-681. 14. Sarkar S, Strutz SE, Frank SM, Rivaldi CL, Sis Texas. PLos Negl Trop Dis 15. Diseases transmitted primarily by arthropod vec tors. In: Kelley PW, ed. Military Preventive Medi cine: Mobilization and Deployment Vol 2. Fort Sam 16. Crisante G, Rojas A, Teixeira MM, Aez N. In fected dogs as a risk factor in the transmission of human Trypanosoma cruzi infection in western Venezuela. Acta Trop 17. infection among deployed US military and civilian workers. Clin Infect Dis 18. hosts and control of zoonotic visceral leishmani asis. Parasitology 19. Ferrer L. Canine leishmaniais: overview. Clini cians Brief at: http://www.cliniciansbrief.com/article/canine2014. 20. AU T H OR S 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 content will MANAGING YOUR DIFFERENTIAL DIAGNOSIS LIST: CONSIDERING BIAS AND RECOGNIZING UNEXPECTED INFECTIOUS AGENTS

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January March 2015 61 Department of Defense Directive 6400.04E 1 designates the Secretary of the Army as the Department of Defense (DoD) Executive Agent for DoD veterinary public and animal health services. This directive is accomplished through the Army Veterinary Services which operates military veterinary facilities throughout the United States (including Alaska, Guam, Hawaii, and Puerto Although these facilities are maintained to provide vet erinary care to the DoD military working dogs (MWDs), but they also provide veterinary care to pets of military mission priorities permit. While the geographic disper sion of the veterinary facilities is necessary to ensure MWDs have timely access to veterinary care, it does present challenges, particularly regarding centralized practice management. Although all US Army veterinary facilities were using a commercial veterinary practice management soft ware program for their patient encounters, the clinics to 2014. While the reliance on paper record systems is transferring radiographs and laboratory results, loss of was necessary due to DoD data network restrictions like prohibition of automatic third party software updates. Additional limitations of the previous system included impaired disease surveillance, network management, and standardization efforts due to the lack of central ized data reporting. In recognition of these restrictions and limitations, the US Army Veterinary Service began exploring options for a veterinary electronic health re cord (EHR) in 2003 A primary prerequisite for the program was that it be 100% web-based with no end user software installation requirement. This was particularly important as the Veterinary Service provides veterinary support for all military services, not just the Army. By stipulating a no-end user software requirement, the Veterinary Ser vice minimized potential issues with individual military requirements. Although not a primary requirement, the program also had to support a geographically dispersed global practice, something not typically necessary for most veterinary EHRs. The Veterinary Service received 7 competing proposals for the original request for proposals, however, only two of them met the primary requirements. Initially, a com potential solution. However, when the product failed ini tial testing, the Veterinary Service sought to modify an other product which had been previously developed for the military, HEALTHeFORCES (HEALTHeSTATE, LLC, Fairfax, VA). HEALTHeFORCES was the EHR for the North Atlantic Regional Medical Command from 1999 until 2004, when it was replaced by AHLTA as the DoD Enterprise System. Following its replace ment, HEALTHeFORCES was transitioned for use in 43 federal and community health centers within West Virginia as HEALTHeWV, 2 strictly as an EHR with no practice management components. EHR subsequent to its selection. Four new practice management components (scheduling, inventory man agement, invoicing, and reporting) were added as part of the Remote Online Veterinary Record (ROVR). Veteri nary personnel participated in all ROVR design meet by personnel from 5 different military veterinary treat ment facilities and by the Veterinary Services Central email, October 24, 2014). The application was beta test ed at 4 locations for 3 to 6 months and independently tested by the Army Medical Department Board at the Fielding the Remote Online Veterinary Record, a Veterinary Electronic Health Record to Improve Patient Care and Practice Management CPT Meghan C. Nelson, VC, USA LTC Ronald L. Burke, VC, USA

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx Army Test and Evaluation Center to ensure it legally met all operational contract requirements prior to full opera The vendor was responsible for the design, development, and delivery of the training required for implementing this program DoD-wide. Initially, a plan was developed to train all personnel at a central location within each US Army Public Health Command District. However, due to funding restrictions, participation was reduced to only key personnel (ie, clinic veterinarian, senior technician, and senior receptionist) from each location being trained in a geographically tiered method at 42 different sites in a train-the-trainer approach. The goal of these training sessions was to have no more than 15 personnel at each site attending the training to maximize student-trainer interaction. The vendor created a training environment for users to practice all of the functions without creat ing real charges or making false medical records within the active production environment. The key personnel subsequently trained individuals who did not attend the initial training. This training was facilitated by an ex tensive training module incorporated within the ROVR application to be used to provide such on-site training. The key personnel training program encompassed 5 days of hands-on learning designed to provide a general working knowledge of the programs functional capabili ties. Each day was dedicated to a different aspect of the program, allowing the new users to experience the entire program prior to implementing the application within their home veterinary facility. Key aspects of the train ing focused on the basic functionality of the application, including scheduling and patient administration, inven data warehousing and reporting, and the capture, stor age, retrieval, and reporting of clinical episodes of care. A large amount of time was dedicated to the use of the eNOTE, which is the actual medical documentation of the veterinary encounter. Within this portion of the EHR, illustrated in the Figure, the user can record all as pects of the encounter from the patients medical history time is also spent reviewing the patient registry func tions in ROVR (diabetes, MWD, and screening regis tries) which allow users to quickly and easily monitor health goals, such as food consumption, body condition, and body weight. Veterinary facilities were required to use ROVR as their sole medical record and practice management program upon completion of the training course. Productivity goals were established to allow the clinics to initially week using the program, 50% the next, 75% the third week, and be fully operational using the application by the fourth week. BENE F IT S O F A VETERIN A RY ELECTRONIC HE A LT H RECORD Perhaps the most important, but as of yet unrealized, Daniel E. Holland MWD Hospital at Lackland Air Force Base, Texas, serves as the DoD role 4 facility for veterinary care. It also serves as the storehouse for all MWD patient records after the animal has retired from military service into adoption, as well as the MWD se rum repository. Veterinary epidemiologists have previ ously used these records and serum to examine morbid ity and mortality trends in MWDs, including potentially zoonotic diseases. 3-5 However, the studies were often retrospective, which present limitations with regard to developing timely policies designed to limit future dis eases. By contrast, veterinary EHRs have the potential sonnel to identify and monitor disease trends. 6 In fact, veterinary EHRs have previously been used to examine whether companion animals can be used as sentinels for zoonotic diseases such as Lyme disease and leptospiro sis. 7 With the implementation of ROVR, the Veterinary Service now has the ability to conduct similar surveil lance among MWDs and also among privately-owned animals. The ROVR provides clinicians with dropdown selection menus for diagnosing their patients, as well as capturing the patients signs and symptoms. Us ers can then query ROVR using keywords to compile a report. The information can be used to identify diseases affecting our pets and military working animals, as well as zoonotic diseases which may affect the service mem ber. This allows preventive measures to be implemented in a timely manner to prevent future cases. Importantly, ROVR has the ability to not only conduct near-real time disease surveillance using case diagnoses, but can also be used to conduct syndromic surveillance as well. For bined with the aforementioned MWD serum repository to conduct seroepidemiologic studies to not only iden tify cases of disease, but risk factors as well. system is enhanced portability of patient records. All MWDs begin their military service at Lackland Air Force Base with the 341st Training Squadron where they receive care at the Holland MWD Hospital. Upon com pletion of their training, the MWDs are assigned to oth er military installations. While the majority of MWDs will spend their entire service permanently assigned FIELDING THE REMOTE ONLINE VETERINARY RECORD, A VETERINARY ELECTRONIC HEALTH RECORD TO IMPROVE PATIENT CARE AND PRACTICE MANAGEMENT

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January March 2015 63 to their respective second installations, a small subset will be stationed at several locations during the course of their years of service. The implementation of ROVR signments and should reduce accidental record losses. Additionally, ROVR will hopefully improve the timeli ness and ease of MWD teleconsultations and the records review required for all MWDs to ensure they are suit able candidates for adoption. Users can also build report functions within ROVR for management and review of MWD records. The ROVR has similarly improved record portability for privately-owned animals when their military own ers are reassigned. Unlike MWDs, privately-owned animals frequently leave and re-enter the military vet erinary system, increasing the likelihood for paper re cord loss. Now ROVR allows a more thorough and well documented medical record to be in place for each pet, potentially covering their entire lifespan instead of hav ing just a few small snapshots of history, as was the case with the old system. erinary Services pharmacy and retail formulary was further standardized and uniform prices were created for all services to provide clients with consistent charges, ly, ROVR improved practice management. It enables the to the Veterinary Services Central Fund (VSCF). Addi tionally, while each clinic still maintains individual au tonomy for their appointments and inventory, the VSCF can now easily look at these items as well to help iden tify and correct issues in real time. For example, the Ap pointment Statistics Report, shown in the Table, enables the VSCF to identify not only issues related to missed or canceled appointments, but also examine whether exam are needed to optimize access to patient care. UN A NTICI PA TED ISSU E S As with any new program, unanticipated issues ap issues was poor connectivity between some of the outly ing sites and the ROVR server. During the beta testing, a 3-ping test was conducted at each location to ensure that the network would be able to support the workload estimated for DoD-wide use of the program. Unfortu nately, the predictions underestimated the actual volume of users that used the server during a typical clinic day. Another factor which further degraded connectivity was clogged bandwidth at individual sites. Several vet erinary clinics shared bandwidth with the local military The eNOTE function within the Remote Online Veterinary Record allows providers to enter all veterinary healthcare infor mation for a patient visit. Each data entry tab has drop-down menus to standardize entry for subsequent data queries. Providers can also create autotext scripts to facilitate routine data entry.

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx medical treatment facilities that use AHLTA, which also fers. In some locations, facilities were still using copper sulted in extremely long refresh times to toggle between the different aspects of the eNOTE, and occasionally re sulted in application lockup at the point of entry. In order to address this problem, the slower networks resources developed and incorporated upgrades. Fixes included upgrades to computer operating systems, bet ter use of route and bridge space to support the clinics cables. A continuous process is in place to work with all local IT departments to troubleshoot and provide bet ter connectivity. Additional IT network solutions, dis cussed below, are also being examined to further im prove connectivity. Another issue that arose was the ROVRs incompatibil ity with Microsoft Internet Explorer (IE) 11. The ROVR was initially created to work with IE8 and IE9 which were the DoD standard at the time of its development. However, several installations have recently upgraded the operating systems to IE11 which created an issue for facilities on those installations. Addressing this is sue required an exemption so individual computers us ing ROVR would not be upgraded to IE11 until ROVR is reprogrammed for compatibility. Aside from network connectivity problems, some users found that the new eNOTE format required substantially more time for entry of all of the required information than did the previous record-keeping system. It is an ticipated that this will improve as users gain familiarity with ROVR, especially the auto text and other timesaving features. Additionally, the program was initially designed to load smaller quantities of data in each tab of the eNOTE which required the user to toggle through several different tabs (Encounter, Clinical Summa ry, Exam/Assessment/Diagnosis, Standard Treatment Plan, Additional Treatment Plan, Laboratory Tests/ forts are currently underway to develop and test a new be available on a single tab. This should eliminate the data lag delays associated with switching tabs. Issues also arose with the veterinary formulary in cal Standardization Board had developed an approved formulary for all veterinary clinics. The most current version of the formulary was provided to the ROVR pro gram developers, but changes were being incorporated into the formulary concurrent with ROVR development. This resulted in omission of new additions to the formu clinic could not use a formulary-approved pharmaceuti cal which was not included in the ROVR inventory, even though it was in stock at the facility. It could only be used after it was added to the ROVR inventory in a fu ture system update. A ROVR help desk was created prior to launching the program to assist users with any issues that arose. Sites can submit requests to the help desk either electronically views the request, and if approved, submits it to the ven and response tickets are now being addressed within 1 to 4 hours as opposed to the initial 8 to 12 hours. Rules FIELDING THE REMOTE ONLINE VETERINARY RECORD, A VETERINARY ELECTRONIC HEALTH RECORD TO IMPROVE PATIENT CARE AND PRACTICE MANAGEMENT Appointment statistics for US Army Public Health Command District Joint Base Lewis-McChord, June 130, 2014, as obtained from the Remote Online Veterinary Record. Facility Monthly Capacity a Percentage of Capacity b Kept No Show Cancelled by Facility Cancelled by Owner Clinical Encounters per Day: Mean Value Beale Air Force Base 360 30% 109 4 5 13 5.32 Fairchild Air Force Base 24 233% 56 1 2 4 2.73 Fort Richardson 360 112% 402 28 13 78 19.61 Fort Wainwright 540 41% 219 10 8 36 10.68 Joint Base Lewis-McChord 1200 45% 542 45 1 86 26.44 Mountain Home Air Force Base 360 51% 185 7 3 17 9.02 Naval Air Station Lemoore 360 52% 186 9 1 12 9.07 Naval Air Station Whidbey Island 540 39% 212 24 9 24 10.34 Naval Base Kitsap-Bangor 540 41% 224 13 1 46 10.93 Presidio of Monterey 24 504% 121 7 0 10 5.90 Travis Air Force Base 360 79% 284 23 3 20 13.85 a. Monthly capacity is a function of the facility tier level, number of examination rooms, and expected number of days open per month. b. Percentage of capacity=kept appointments/monthly capacity

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January March 2015 65 have also been created for pass through incidents, al lowing tickets that meet certain rule to go straight to the ROVR support team for immediate resolution. Exam ples include tickets pertaining to creating new accounts, a user changing facilities, or inactivating accounts. To date there have been several new builds to streamline a majority of the missing formulary inventory items change is the eNOTE function now contains canine den tal images to more clearly document oral issues. Addi tional template forms such as phone consultations are being added on a regular basis to meet user demand. FU T U RE DIRECTION S Although establishment of the ROVR help desk and similar efforts have helped to address many of the is sues with ROVR, additional work is still necessary. For example, while the connectivity issues have been eased with upgrades to operating systems and changes to net work routing, they are not yet fully resolved. In addition to the previously mentioned improvements to local net work infrastructure, other potential solutions currently under consideration include development of regional servers to reduce demand on the main server and func tion as back-ups, and creating the ability to store patient data locally to be uploaded to the server later when a network connection would not be required. Another improvement currently under development in volves patient care in a deployed setting. The ROVR was launched for a 30-day trial in theater with the 72nd Medical Detachment Veterinary Service Support (VSS) unit beginning in mid-July 2014. During this trial pe riod, only MWDs were tracked in the system since a method for tracking contracted dogs in ROVR had not yet been created. Over the course of the trial, users were directed to keep a log documenting what went well with the application and any issues they encountered. While record portability and enhanced access to full medical records, the evaluation ultimately concluded that ROVR was not ready for use in the deployed environment due to several limitations (LTC N. Chevalier, 72nd VSS Commander, email, October 31, 2014). Most of the limi tations resulted because ROVR was created for garrison veterinary facilities, and many of the assumptions for garrison did not apply in the deployed environment. For example, ROVR has a standard inventory based on the Veterinary Medical Standardization Board (VMSB) for mulary which is supported by the VSCF prime vendor program. However, in the deployed environment, medi cations are procured from Medical Logistics instead of directly from a civilian prime vendor. This means that most of the medications used in theater are human medi cations which are not approved in the VMSB formulary, and consequently not found in the ROVR inventory. Another issue was related to the ROVR designation of the 72nd VSS as a single entity under the name OEF 1 Vet Det. This was done partly to maintain operational ward operating bases or areas of operation. However, this designation caused the program to assume that all veterinary teams were collocated in the same facility, which was not the case. The ROVR inventory is de signed to assume that all items are located within that one facility, not spread across several locations. This available and used. Solutions to these deployment-relat ed issues are currently under investigation. CONCL US ION to globally manage the militarys veterinary practices and has access to more reporting capabilities. It is an ticipated that as the application matures and evolves, a greater dataset for epidemiology and disease control will be available. Additional future developments to this program should include the capability of uploading radiographic images for real time consultation, as well as interface capabilities with external third parties such as laboratories allowing automatic entry of test results into the program, thus eliminating another manual entry function of the user. The ultimate goals of creating the global program are sive and active disease surveillance for MWDs and best practice management for different diagnoses. As the program continues to mature and the dataset grows larger, the possibilities for use of this program have only begun to emerge. RE F ERENCE S 1. Department of Defense Directive 6400.04E: DoD Veterinary Public and Animal Health Services Washington, DC: US Dept of Defense; 2013. 2. HEALTHeSTATE, LLC. Our Remarkable Story. Available at: http://www.healtheforces.com/ourstory/. Accessed October 26, 2014. 3. Havas KA, Burkman K. A comparison of the se rological evidence of Coxiella burnetii exposure between military working dogs and feral canines in Iraq Mil Med 2011;176:1101-1103.

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66 http://www.cs.amedd.army.mil/amedd_journal.aspx 4. Moore GE, Burkman KD, Carter MN, Peterson MR. Causes of death or reasons for euthanasia in military working dogs: 927 cases (1993-1996). J Am Vet Med Assoc 2001;219:209-214. 5. Burkman KD, Moore GE, Peterson MR. Incidence of zoonotic diseases in military working dogs serv ing in Operations Desert Shield and Desert Storm. Mil Med 2001;166:108-111. 6. Day MJ, Breitschwerdt E, Cleaveland S, et al. Sur veillance of zoonotic infectious disease transmitted by small companion animals. Emerg Infect Dis [in ternet]. 2012;18(12). Available at: http://wwwnc.cdc. gov/eid/article/18/12/12-0664_article. Accessed October 26, 2014. 7. Glickman LT, Moore GE, Glickman NW, Cal danaro RJ, Aucoin D, Lewis HB. Purdue Univer lance Program for emerging and zoonotic diseases. Vector Borne Zoonotic Dis 2006;6(1):14-23. AU T H OR S CPT Hunter is the Veterinary Chief, Joint Base Elmen dorf-Richardson (JBER) Branch, Public Health Com mand District Joint Base Lewis-McChord, JBER Alaska. LTC Burke is the Veterinary Public Health Instructor for the First Year Graduate Veterinary Education Program, Joint Base Lewis-McChord, Washington. FIELDING THE REMOTE ONLINE VETERINARY RECORD, A VETERINARY ELECTRONIC HEALTH RECORD TO IMPROVE PATIENT CARE AND PRACTICE MANAGEMENT

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January March 2015 67 The First Year Graduate Veterinary Education (FYGVE) program was initiated in August of 2010. The year-long rotating internship is intended to provide exposure and reinforcement of those skills necessary for suc cess in providing military veterinary medical services to the Department of Defense (DoD) 1 in accordance with Army Regulation 40-905 2 First year internship programs exist in the Army Medical Corps and Army Dental Corps, but those are primarily clinically-focused. The FYGVE program includes public health and leader ship tracks, in addition to clinical medicine. The duty placed at isolated, single veterinarian duty sites, includ ing Marine, Navy, and Air Force installations that may be located hundreds of miles from their peers or chain in their clinical abilities, but also must be prepared to manage Soldiers and civilians and oversee the procure ment and protection of food for the installation. These diverse requirements are not adequately addressed in the typical veterinary school curriculum. The FYGVE best opportunity to succeed. This article is a retrospec tive review of the FYGVE program at Joint Base Lewisas experienced by three of the interns. It details how the program affected readiness and the ability to excel in the following areas of emphasis: animal medicine, food protection, public health, and leadership/management. BA CKGRO U ND Proper mentorship is critical to the development of new veterinarians as they transition from the role of student to doctor. New graduates often search for mentors as they enter the work force. A licensed veterinarian is le gally able to treat any species of animal, but there are far more clinical situations than could ever be covered in a 4-year postbaccalaureate curriculum. This is especially the full medical and surgical support of military work lation commanders of matters of public health, to over seeing the procurement of safe food for all of the DoD (through the commercial sanitation audit program), to veterinary clinic. In addition, the young veterinarians are commissioned as captains in the US Army, thereby becoming not only a Soldier, but a leader as well. At foundation of knowledge, However, it only paints a lim functions are unveiled through the FYGVE program and The typical FYGVE program has 4 to 6 interns overseen by 2 FYGVE cadre, one boarded in veterinary preven tive medicine and the other in a clinical medicine spe cialty (eg, surgery, internal medicine). While this article presents a review of the program at one site (JBLM), it is important to note that execution of FYGVE programs varies greatly between sites. The locations of all FYGVE programs are shown in the Figure. At JBLM, the interns split time between clinical medicine and public health rotations. Interns spent from 2 to 6 weeks in any rotation, for follow up on clinical cases or commercial sanitation audits, as needed. Interns could elect to schedule their own patient rechecks from 8 AM to 9 AM cial rotation starting at 9 AM terns to follow up on their own clinical cases even when they had moved on to the public health rotation. While this was not a requirement, the continuity it provided was very useful from a learning perspective. The interns found the opportunity to conduct their own rechecks helpful for their professional development as clinicians. Joint Base Lewis-McChord First Year Graduate Veterinary Education: Observations and Lessons Learned CPT Aimee Hunter, VC, USA CPT Teresa Villers, VC, USA CPT Lauren Seal, VC, USA David Galloway, DVM

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68 http://www.cs.amedd.army.mil/amedd_journal.aspx ANIM A L MEDICINE The FYGVE program provides animal medi clinical instructor while practicing in a referral level veterinary hospital. The specialist is typi small animal surgery, radiology, or emergency/ critical care. The JBLM site had an internal med icine instructor. The clinical instructor provided guidance during daily case round discussions, continuing education through monthly case pre ing clinical credentialing in both medicine and surgery. Each FYGVE site has a Veterinary Cen ter (VETCEN) as the animal medicine platforms. The VETCENs are the highest tier installation veterinary medical facility in the Army Public Health Command. The centers are equipped and staffed for routine to referral-level animal medi cal care and have an animal medical training ca pability. The JBLM VETCEN was fully staffed, including 2 full-time civilian animal care techni sick call appointments scheduled from 9 AM to 12 noon, 9 AM PM The interns had the option of keeping any patients that required extensive workup or care for the afternoon. Equipment was up-to-date and readily avail able for use, providing hands-on experience with ultra sound, digital radiographs, in-house blood work, cytol is not typical of the average smaller military veterinary facilities, providing the interns the opportunity to learn as much as possible from a clinical perspective during their FYGVE year. Leaving the program clinically credentialed in medicine workups without direct supervision on governmentgeries and advanced workups immediately. The key to uous learning through repetition. The JBLM VETCEN maintains a heavy caseload, which allows interns to learn something new each day. That knowledge base clinical instructor and peers at the end of each day. In terns also had the opportunity to work up complicated care. However, it was understood that interns, not enlist ed veterinary technicians, provided overnight care for in-house. This experience was important because it con veyed to interns that Soldiers, whose primary responsi not priority missions without due consideration of the lesson in mission priorities promotes an understanding of better Soldier care and utilization by their leaders. The MWD population at JBLM offered each intern the opportunity to work with MWDs at least once month ly. These encounters typically involved completion of for a MWD emergency, such as a splenic torsion or un controlled seizing. In these instances, all interns were given the opportunity to be involved through provision of overnight critical care case management and followon case discussion. Each intern also completed animal facility inspections, including the MWD kennel and Child Development Center classroom pet care. JOINT BASE LEWIS-MCCHORD FIRST YEAR GRADUATE VETERINARY EDUCATION: OBSERVATIONS AND LESSONS LEARNED C D E F G H B A Site Start Site Start A Ft Belvoir FY10 E Ft Hood FY12 B Ft Bragg FY11 F Ft Campbell FY13 C Joint Base Lewis-McChord FY11 G Ft Benning FY13 D Ft Carson FY12 H Camp Pendleton (USMC) FY16 Locations of current FYGVE sites and the year each program began. Camp Pendleton, California, will be implemented in FY 16

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January March 2015 69 At JBLM, interns did not complete deployment records for MWDs, nor execute any of the monthly record re views, although a didactic session was performed. The preparation and maintenance of records is extremely im without the assistance of an experienced enlisted veteri hands-on task to perform during FYGVE, especially that links all military veterinary facilities.* (Note: the hands-on component of record preparation and manage ment is now a requirement in the current FYGVE cur riculum.) Now that record reviews must be completed tion portal, the FYGVE would also provide an excellent opportunity to create and teach a universal method to complete monthly record reviews. the FYGVE program is the difference between what is available during the program compared to what will be equipped and staffed VETCEN imparted false expecta tions to some interns as to what would be waiting for them at their next assignment. The JBLM VETCEN has full surgical capability, radiology, ultrasound, and ophthalmic exam equipment. It is also fully staffed with civilian and military veterinary personnel to assist with the very large and demanding clinical mission. Interns next assignments. It is understood that different clinics have different capabilities, however, it would be useful if tinuum of care across veterinary facility tiers and levels of care. This information should include treatment alter natives under resource constraints and case-based dis cussions of referral/evacuation procedures that ensure Standardization Board guidelines. This area of training will be addressed in future years with required rotations to smaller VTFs, which will be more indicative of the resources interns will have at their next assignment. All follow-on assignment locations were also experiencing side, having completed the FYGVE experience, the in terns felt they were better equipped than their peers who assignment. They also knew to reference Army regula tions and how to obtain the resources that allow them to perform their animal health mission and prevent Soldier burnout in the process. PU BLIC HE A LT H/FOOD MI SS ION The FYGVE program provided additional mentor ship through a public health instructor. The instructor worked with the Public Health Command District and/or defense, to ensure each intern quickly achieved phase quired to complete food protection audits without su site. An Acceptable Commercial Sanitary Audit rating tablishment can be listed in the Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement This listing is necessary to sell to the DoD. For continued listing as an approved source, with Military Standard 3006A 4 Compliance with this standard ensures that facilities are producing safe and wholesome food to minimize the risk of food-borne illness to service members and their families. Interns transitioned from staff auditors to lead auditors, becom ing competent in performing food protection audits and This allowed a smooth transition to performing sanitary audits at their next assignment, as well as helping to pre pare interns to volunteer for and complete Food and Wa ter Risk Assessments (FWRA) outside the continental US in accordance with Military Standard 3041 5 These approved food sources to support short-term exercises. as well as risk mitigation, regarding a particular food es tablishment. 6 audit mission. Each intern completed numerous audits, an average of 15 different facilities each compared to an average of 9 audits per intern at other FYGVE sites increased audit load improves competency and more the next duty site where there is likely less opportunity for face to face mentorship. Many public health topics were discussed during weekly FYGVE public health classes. Topics included zoonotic diseases, installation rabies board policy, bite reports, foreign animal diseases, response to refrigeration fail ures, the human-animal bond, and inspection of opera tional rations (eg, meals ready-to-eat). Though these See related article on page 61

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70 http://www.cs.amedd.army.mil/amedd_journal.aspx are broad topics, classes provided important resources that interns have frequently applied at current assign ments. These classes directly led to the creation of ra bies advisory boards at two sites, improved bite report standards, and improved communication on animal dis plays (such as petting zoos) on military bases. At JBLM, interns also completed the ServSafe program (National Restaurant Association, Washington, DC), which is ac credited by the American National Standards Institute Conference for Food Protection. The ServSafe program is very useful for gaining knowledge of proper prepa ration and storage of food to reduce risk of foodborne illness. It gave the interns greater baseline knowledge of food safety, a topic that receives limited instruction in most veterinary school curricula. The interns rec ommended that this be added as a formal part of the FYGVE program. Areas in public health for which interns felt less pre the Installation Food Vulnerability Assessment (IFVA) program, IFVA team development and its annual brief ing to the installation commander in accordance with the US Army Food and Water Vulnerability Assessment Guide ,* approved sources tracking for temporary ven dors such as food trucks on the installation, the role of Veterinary Services in Moral, Welfare, and Recreation special events, and involvement of Veterinary Services in installation emergency support plans. Additionally, although interns were given a brief didactic introduc tion to the Installation Support Plan, (the program the commissary, post exchange (PX), and shoppettes), no sanitary inspections were performed as part of the their responsibilities, the former interns are required to complete sanitary inspections regularly at their new duty sites. The FYGVE program now requires an IFVA mander and a requirement of performing 5 commissary and 5 PX/shoppette visits. LE A DER SH I P/ MA N A GEMENT The development of leadership skills and management ability is a core aspect of the FYGVE curriculum. The leadership training that the interns received at JBLM out to leaders in other commands and organizations on their respective installations. A number of the interns reached out to base commanders immediately upon reaching their follow-on assignment and now collabo rate with a variety of commands and organizations on the installation. However, interns felt that the handson component of the leadership curriculum needed improvement. The leadership component of the program there is a leadership rotation and concrete benchmarks for interns to achieve. This rotation includes positions organizational, leadership, and administrative tasks. A unique aspect of the JBLM program was a leadershipfocused book club. Interns read several books through out the course of the year and then met for discussion. the program that has since been implemented at other cycle for FYGVE at JBLM, all interns, cadre members, and the regional commander were female. That unique situation made discussions regarding women in leader pants of this FYGVE iteration. An area of leadership training phase that the interns felt could be improved was counseling and development of subordinates. FYGVE interns were not afforded partici pation in integrated roles of leadership such as rating Soldiers, dealing with challenging situations, writing awards, etc. Though each intern was given the oppor tunity to issue a positive counseling statement to a Sol dier of his or her choice, there was no opportunity to witness or contribute to developmental or disciplinary interns do not directly supervise any Soldiers and the privacy of the individual counseled must be respected. experiences with these matters. Instead, group discus sions of hypothetical scenarios and role playing were implemented to serve as an introduction to real world problems. Interns felt that this area should have received since Soldier development is one of the most important Similarly, management of civilian employees was cov ered in a couple of one-hour training sessions, but did not prepare interns for the administrative burden of rat ing, rewarding, reprimanding, and counseling civilian employees. Interns also did not receive a thorough in troduction to the responsibilities and roles of employees within the Veterinary Services Central Fund (VSCF), the nonappropriated fund (NAF) entity that oversees ties, separate from the operational chain of command. This group assists with reviewing income statements and general business management. The VSCF and the JOINT BASE LEWIS-MCCHORD FIRST YEAR GRADUATE VETERINARY EDUCATION: OBSERVATIONS AND LESSONS LEARNED

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January March 2015 71 NAF Civilian Personnel Advisory Center assists with civilian hiring/disciplinary matters as well as other hu man resources functions. The process for hiring civilian employees is an important topic that was not discussed cause all interns were faced with vacant positions upon towards FYGVE interns to better prepare interns for veterinary clinic manager level tasks. Teleconferences with VSCF did occur, however, they were of limited year from a leadership/management perspective was the provision of resources for the future. Examples of coun seling statements and annual evaluations were provided stances were cited for interns to review. In addition, be ing stationed at a site where branch, district, and region al public health commands were located gave interns an excellent opportunity to be exposed to several types of leadership styles. Not only were the instructors 100% dedicated to preparing the interns for success in their fu ture assignments, the chain of command also was fully engaged all the way through the regional command lev placement of the right people in the FYGVE instructor interns who participate in the program. Without cadre, district, and regional commanders who care about the program will not be realized. REL A TION SH I P BU ILDING as number of commercial audits, clinical credentialing, relationships with fellow interns, instructors, and non each intern to identify their strengths and weaknesses, and they were then able to work with each other to build on both. The bonds created during the FYGVE program have also translated into excellent working relationships with numerous Public Health Command personnel. For mer interns now have contacts around the Veterinary Corps for questions, concerns, and advice, ranging from former instructors, intern-mates, food inspectors, have gone to their separate assignments, they continue to use their FYGVE colleagues as sources of perspec tive and knowledge as they encounter unique situations at their individual duty sites. The bond they now share perhaps the most unexpected advantage gained through participation in the program. A solid foundation of clini propriately on veterinary treatment facility management, mission accomplishment, and leading Soldiers. SU MM A RY The FYGVE program provided a solid foundation to smooth the transition from veterinary student to Vet resources and exposure to vital areas of the mission, it also produced a network among interns and their in structors. This network was critical to their success as they assumed their next assignments. Interns left the in clinical medicine, public health, and food safety. Im provements in the leadership/management track are al ready being added to the program. At the end of each internship year, an extensive after action report (AAR) is conducted. The AARs solicit feedback from interns and cadre alike. Many of the improvements added to the program have come directly from these retrospective about the direction for the future of the program and the effect of possible budget cuts. This article presents the positive aspects and concerns of the program at JBLM, all interns moved into the role Current duty sites for the intern authors are Kings Bay Submarine Base, Redstone Arsenal, and Fort Bliss. The intern assigned to Fort Bliss moved into the role of Chief of Veterinary Services for the Fort Bliss Branch a year after completion of the internship. This role includes oversight of 4 Veterinary Treatment Facilities that span 2 states. More than a year after completion, all interns agree that the FYGVE program provided a background that was integral to their success at their current duty stations. RE F ERENCE S 1. Torring EH, Mey W. US Army Veterinary Corps First Year Graduate Veterinary Education Program. US Army Med Dep J

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72 http://www.cs.amedd.army.mil/amedd_journal.aspx 2. Army Regulation 40-905: Veterinary Health Servic es Washington, DC: US Dept of the Army; 2006. Worldwide Directory of Sanitarily Approved Food Establishments for Armed Forces Procurement Aberdeen Proving Ground, MD: US Army Pub lic Health Command: 2014. Available at: http:// phc.amedd.army.mil/topics/foodwater/ca/Pages/ DoDApprovedFoodSources.aspx. Accessed De cember 9, 2014. 4. MIL-STD-3006C: Sanitation Requirements for Food Establishments Washington, DC: US Dept of Defense; June 1, 2008. Available at: http://quick search.dla.mil/qsDocDetails.aspx?ident_num ber=208822. Accessed December 9, 2014. 5. MIL-STD-3041: Requirements for Food and Water Risk Assessments Washington, DC: US Dept of search.dla.mil/qsDocDetails.aspx?ident_num 6. Killian JW, Burke RL, Westover JE. Food and wa ter risk assessments: empowering commanders and protecting service members. US Army Med Dep J AU T H OR S CPT Hunter is the Chief of Veterinary Services, Fort Bliss Branch, US Army Public Health Command Dis trict Carson, Fort Bliss Texas. Veterinary Section, US Army Public Health Command District Fort Gordon, Redstone Arsenal, Alabama. nary Section, US Army Public Health Command District Fort Gordon, Naval Submarine Base Kings Bay, Georgia. Dr Galloway is the FYGVE Program Manager in the Virginia. JOINT BASE LEWIS-MCCHORD FIRST YEAR GRADUATE VETERINARY EDUCATION: OBSERVATIONS AND LESSONS LEARNED

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January March 2015 73 Traumatic brain injury (TBI) and other blast-related in juries are likely to be an enduring legacy of Operations Iraqi Freedom and Enduring Freedom. 1,2 Improvised explosive devices were the primary causes of exposure to blast energy and projectile material. The primary sci mitigating blast exposure risks have been the lack of data on the long-term sequelae from individual blast expo sures, as well as lack of information regarding the rela tionship between relatively minor, cumulative exposures and brain injury symptoms. Several studies to date have 3-8 Primarily due to the wars in Iraq and Afghanistan, a great deal has been learned about mechanism of injury and pathophysiologic effects of blast-induced TBI. 5,6,9-12 There have been several animal and human studies doc umenting metabolic, molecular, cellular, and systemic effects from the primary blast injury along with several theories of injury mechanism. 3,5,7 Regardless of mecha nism, these injuries are typically at the chemical and/ or microscopic level which are impossible to appreci ate with the diagnostic modalities available in a combat mined in that setting. 5 McCrea et al 13 mine in the combat setting that confusion after a blast event is due to brain injury or psychological trauma. Thus, many Soldiers may meet the diagnostic criteria for mild TBI (MTBI) symptoms without having suf fered any physiologic injury. Further, Walker et al 14 states that loss of consciousness at the time of injury is an important factor in determining risk for long-term sequelae, and that immediate evaluation by a provider is key to clarifying later diagnoses. There is typically a between point of impact and a thorough medical evalu ation. The lack of physical injuries that can be readily observed in the operational setting have made it neces sary in many instances to diagnose MTBI on the basis of exposure history as recalled by the service member and subjective complaints. Many of these symptoms such fatigue, increased sensitivity to noise and light, insom nia, irritability, decreased concentration, and anxiety Associations Between Operationally Estimated Blast Exposures and Postdeployment Diagnoses of Postconcussion Syndrome and Posttraumatic Stress Disorder MAJ Jonathan L. Saxe, SP, USA Christopher L. Perdue, MD, MPH AB S TR A CT in Iraq and Afghanistan. Some operational units in Iraq, especially those responsible for clearing roadways, were exposed to hundreds of blast incidents and thousands of individual doses of concussive energy during their lengthy deployments. Using operational records maintained by a single command element, the researchers conducted a retrospective cohort study evaluating the association between estimated individual exposures to blasts and the risk for postconcussion syndrome (PCS) and posttraumatic stress disorder (PTSD). Tactical records documented all of the relevant details of the subjects exposures to blasts during their missions. During the study period there were 313 blasts involving 418 service members resulting in 4,250 blast person events. Of that population, 12.9% were diagnosed with PCS, 8.6% with PTSD, and 5.3% with both. This study suggests that estimating the total individual dosage to concussive forces through physical evidence at the scene could be a useful predictor of future brain-disorder diagnoses. Those in vehicles sustaining heavy blast damage are at increased risk of being diagnosed with PTSD with a rate ratio of 2.79 (95% CI 1.27-6.13) and PTSD in conjunction with PCS with a rate ratio of 4.10 (95% CI 1.63-10.28). Standardization of the data collection method for blast incidents and additional follow-up studies could lead to the development of better ways of monitoring operational risk factors for negative health outcomes, plans to intervene in order to minimize health

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx are shared with acute stress reactions and PTSD. 15,16 Hoge et al 6 argues that there are many psychological phenomenon that may produce an apparent alteration in for providers in theatre to make informed prognostic de units mission readiness resulting from unfavorable Sol dier health outcomes. study the relationship of MTBI, PCS, and PTSD. Hoge et al 6 found MTBI and PTSD to be strongly associated with 40% of Soldiers meeting criteria for PTSD who supported in further investigation by Wilk et al. 17 A study by Meares et al 18 for psychological comorbidities in contributing to a symptom-complex that appears to be PCS. Bryant 15 ad dresses possible physiologic sources of PTSD in patients with MTBI, noting that the prefrontal cortex is often in may further confound the clinical course of PCS/PTSD, in that distinguishing one diagnosis from the other be comes more challenging. Soldiers who self-reported exposure to blasts perceived themselves to have poorer health, missed more work days, and were more symptomatic than Soldiers who were not exposed to blasts. 6 A study by Sim et al, 19 concept that, on average, concussions result in shortmemory dysfunctions, and cognitive processing delays) that resolve differentially over time. However, Vagnozzi et al 20 demonstrated lingering neurometabolic sequel ae due to concussion among civilian athletes. Further, Trudeau et al 16 speculated that the physiologic sequelae more permanent and result in prolonged PCS. This is 2 that Soldiers who had a documented TBI were more likely to report post concussive symptoms upon redeployment (7.5%) than those who did not (2.3%). With all of the challenges surrounding surveillance, diag nosis, and treatment of blast-related exposures and health outcomes, there is a rational need for better tools to col lect information in operational settings. A tactical tool for measuring blast dosimetry with information readily into predictive values for the development of long-term injury would be invaluable. This study is unique in that we compared individual operational exposure data to the mulative exposure estimates that may lead to operational decisions aimed at reducing the likelihood of PCS/PTSD. MET H OD This retrospective cohort study, approved through the Iraq Deployed Combat Clinical Research Team and the human subject review board at the Brooke Army Medi cal Center, Texas, included data for personnel assigned to 3 companies of combat engineers deployed to Iraq be tween (approximately) October 2006 and January 2008. Those 3 companies were chosen because of the similar ity of their missions, geographic proximity in northern Iraq, and their shared command. Permission to use tacti cal records for the purposes of this study was provided by the brigade commander at that time. Tactical records documented all of the relevant details of the subjects exposures to blasts during their missions. A variable number of subjects were engaged in tactical route clearance missions nearly every day of the de ployment, though blasts did not occur on every mission. Only missions during which a blast occurred received documentation and was therefore suitable for inclusion in the study. Subjects traveled only by military armored vehicle (not by foot) during missions. During a mission, normally resulting in exposure of a single vehicle dur ing an explosion, though occasionally 2 vehicles were affected. Missions during which a blast occurred were described in detail in narrative documents, spreadsheets, photos, and digital drawings that were provided to the this study were manually abstracted by the primary au Data included the vehicle order during the mission, the relationship of the vehicles to the blast, seat-assignment of each subject, and the level of damage to the vehicle as a result of the blast. The exact date of the blast event was tween blasts were transformed into the number of days from the beginning of data collection (the day of the assignments included the driver, front passenger, gunner (located in a turret protruding through the roof of the vehicle) or a rear passenger on either the same side or the opposite side of a documented blast. Not every vehicle had a gunner or rear passengers. Vehicles directly in line with the explosion were consid ered targeted, and thus the passengers of that vehicle were targeted as well. Precise proximity of a targeted ASSOCIATIONS BETWEEN OPERATIONALLY ESTIMATED BLAST EXPOSURES AND POSTDEPLOYMENT DIAGNOSES OF POSTCONCUSSION SYNDROME AND POSTTRAUMATIC STRESS DISORDER

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January March 2015 75 vehicle to a blast and the estimated size of the blast were not consistently available. Blast intensity was estimated by classifying the level of damage to each vehicle on a 4-point scale based on the information available in the tactical records. After no damage, minor damage in cluded paint or glass chips, blown-off external acces to the wheel or drive system. Moderate damage includ ed visible cracks through one or more layers of glass, dents in the exterior armor, or damage to the wheel or drive system which sometimes left the vehicle inoper able. Heavy damage included penetration of the passen ger cabin or damage to the engine block or chassis and meant that the vehicle was no longer drivable. The blast intensity was used to estimate individual ex posures in one of 3 models based on the blast damage assessment of the vehicle. In the simplest model, a blast dose was assigned to each individual present on a mis sion consistent with the level of damage to the vehicle in which they traveled on a scale of 0 to 3, 3 being the highest. Subjects in a vehicle that was not directly tar geted (eg, all of the other vehicles in the convoy), as well as those in a targeted vehicle that suffered no damage, were assigned a blast intensity of zero. Because gunners were partially external to the vehicle cabin, the gunner model postulated the he was ex posed at a level above that of the other passengers. The based on the amount of damage to the vehicle, but with the gunner receiving one point higher than any other passenger in the same vehicle. Finally, the laterality model took into account the position of each person in the vehicle in relationship to the blast. Those in a gunner position or ipsilateral with respect to source of the blast were considered to be more exposed (by a value of one) than those contralateral to the blast. The laterality model described blast exposures on a scale of 0 to 7. For each individual, the cumulative blast intensity score (BIS) for the entire deployment was the sum of all individual exposures under each of the models. Diagnoses of PTSD and PCS were determined using data from the Defense Medical Surveillance System (Armed Forces Health Surveillance Center, www.afhsc. care encounters during which PTSD (ICD-9-CM code 309.81) or PCS (ICD-9-CM code 301.2), respectively, were documented as the primary diagnosis during the 365 days following deployment. Also included were subjects with 2 or more encounters with the diagnosis of were excluded if, during the year following deployment, the healthcare record indicated that the subject suffered a concussion or other head injury requiring medical treatment, that is, a postdeployment incident. calculated using standard formulas. Bivariate and mul tivariate logistic regression models using SAS 9.0 (SAS Institute Inc, Cary, NC) were used to conduct sensitivity testing of our 3 observational models. We examined the relationships between the cumulative BIS, sex, age, the total number of times a subject was on a mission during which a blast occurred, and (independent of the BIS) the total number of times a subject was in a targeted vehicle. RE SU LT S Over the study period, 477 service members were as signed to route clearance missions. The population was similar to other combat arms units with 99% male, 92% enlisted, and 72% aged 18 to 30 years. Other demo graphic and socioeconomic data were not available in this study, and the individuals themselves were never contacted by the study team. During 366 days of observation, there were 313 blasts resulting in 4,625 individual potential exposure events (ie, the number of people in convoys multiplied by the were incorrectly transcribed during data collection and they could not be matched to health care record in the Defense Medical Surveillance System. Soldiers dropped from the study had a distribution of blast exposures that was consistent with those who were retained (data not shown). After the exclusions, the data included 418 ser vice members with 313 blast events and 4,250 potential exposures. A total of 278 subjects were present in vehi cles that appeared to have been directly targeted during a blast, resulting in 940 individual blast exposures. Accumulation of blast incidents over the course of the study period on a relative time scale from the begin ning of observations was well distributed. More blasts deployed personnel were at risk for blast exposures for most of the deployment. Further, blasts resulting in vehi cle damage were also evenly distributed throughout the study period. Sixty blasts caused minimal vehicle dam age and exposed 210 Soldiers; 50 blasts caused moderate vehicle damage and exposed 157 Soldiers; and 8 blasts caused heavy vehicle damage that affected 28 Soldiers. Outcomes of PCS and PTSD were not evenly distributed among the population as shown in Table 1. Enlisted Sol diers had higher rates of PCS and PTSD at 13.8% and

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx and PTSD. Those aged 30-34 years had the highest rate of PCS and PTSD at 22.6% and 14.5%, respectively, as well as the highest rate of diagnoses with both (11.3%). The crude risk ratio (CRR) for developing PCS for those (CI), 0.87-2.37), for developing PTSD was 1.46 (95% CI, 0.70-3.06), and for developing both PCS and PTSD together was 3.92 (95% CI, 1.88-8.18). There were no in this study. Soldiers on more than one mission during which a blast occurred (regardless of their individual or cumulative blast exposure) had a CRR for the diagnosis of PCS of 2.69 (95% CI, 1.10-6.55), as shown in Table 2. Being in a targeted vehicle at least once increased that risk to 2.9 (95% CI, 1.41-5.97). Being present during more than one cant, risk of developing PCS. Being in any blast during which the vehicle experienced heavy battle damage did not predict a diagnosis of PCS in the postdeployment period. being on missions during which blasts occurred; nor was it associated with being in a targeted vehicle as a single event. However, PTSD was strongly associated with being in more than one targeted blast (CRR 4.54; 95% CI, 1.56-13.2), which became somewhat less pro nounced with increasing numbers of exposures. Being in a vehicle that received heavy damage from a blast was also highly correlative with a diagnosis of PTSD during the 12 months following deployment (CRR 4.10; 95% CI, 1.63-10.28). Sensitivity analysis of the blast models was crudely evaluated by establishing sequentially increasing cut-off values between not exposed and exposed based on the cumulative blast intensity score derived from the battle damage assessments. The crude rate ratios for diagnosis of PCS for the 3 blast intensity models (any targeted incident, simple, gunner, or complex) are con sistent across various cutoff values for blast intensity scores, suggesting that no model was particularly better at predicting outcomes. The data for those models are presented in Tables 3, 4, and 5. COMMENT In our opinion, the best data is derived from the targeted exposures. Soldiers in vehicles targeted 2 to 3 times and those in vehicles sustaining heavy battle damage show a strong correlation to being diagnosed with PTSD, and an even stronger correlation to PCS together with PTSD. risk ratios in diagnosis of PCS, PTSD, and both PCS/ PTSD together for each given level of exposure. Our ference in the risk of diagnosis between PCS, PTSD, and both PCS/PTSD together per given exposure level after a Soldier has been targeted more than once. This may be indicative of the similarities between these 2 diagnoses, er since there are no readily available objective markers for what may be their instigating injury (MTBI) as well as their similar clinical pictures. This data supports the Hoge et al research in that PCS and PTSD are strongly associated. 6 Our study indicates Soldiers aged 30-34 years are more likely to be diagnosed with both PCS and PTSD. Sol diers in this age range are more likely to have been pre viously deployed but typically remain in positions with high exposure to blasts. These Soldiers may have some residual injuries/illnesses from their previous combat ASSOCIATIONS BETWEEN OPERATIONALLY ESTIMATED BLAST EXPOSURES AND POSTDEPLOYMENT DIAGNOSES OF POSTCONCUSSION SYNDROME AND POSTTRAUMATIC STRESS DISORDER Table 2. Crude Risk Ratios (CRR) for Levels of Blast Exposure Exposure PCS CRR (95% CI) PTSD CRR (95% CI) Both CRR (95% CI) >1 mission 2.69 (1.10-6.55) 1.70 (0.68-4.25) 2.74 (0.65-11.52) Targeted at least once 2.90 (1.41-5.97) 1.76 (0.83-3.77) 3.19 (0.96-10.6) >1 targeted blast 2.63 (1.49-4.61) 2.02 (1.04-3.93) 4.54 (1.56-13.2) >2 targeted blasts 2.83 (1.69-4.73) 2.33 (1.24-4.38) 4.43 (1.77-11.09) >3 targeted blasts 2.83 (1.74-4.61) 1.80 (0.96-3.40) 3.40 (1.51-7.65) Any blast resulting in heavy BDA 1.74 (0.82-3.71) 2.79 (1.27-6.13) 4.10 (1.63-10.28) Table 1 Crude Risk Ratios (CRR) for Diagnoses by Demo graphic Groups. Age (years) Any PCS Any PTSD Both CRR 95% CI CRR 95% CI CRR 95% CI <25 R EF R EF R EF 25-29 0.62 0.31-1.23 0.55 0.23-1.33 1.58 0.69-3.60 30-34 1.54 0.87-2.73 1.46 0.70-3.06 3.92 1.88-8.18 35-39 0.19 0.03-1.35 0.28 0.04-2.02 0.48 0.06-3.62 >39 0.19 0.03-1.35 0.28 0.04-2.02 0.48 0.06-3.62 Service Status Enlisted 4.54 0.65-31.8 3.00 0.42-21.2 1.80 0.25-13.0 Officer R EF R EF R EF Note: R EF indicates reference population on which all calculations are based.

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January March 2015 77 There appears to be an association between blast expo sure and the diagnosis of PCS and PTSD. This relation ship appears to remain fairly constant despite not only an increasing number of exposures but also an increas ing exposure intensity score. This denies us the ability methods that may lead to operational decisions aimed at reducing the likelihood of PCS/PTSD. The investigators surmise this may be secondary to the fact that there are fewer subjects as blast intensity scores increase. There simply may have been too few subjects at the higher lev els of exposure to clarify the subtle differences. It may also be due to our imprecise way of measuring blast vehicle damage to blast sensor readings, and use that data in a similar study. Our negative results could fur ther be secondary to our method of collecting outcome data. We collected data only on those who met criteria for PCS and PTSD and did not imply diagnosis based on symptom complexes. Alternatively, we could have criteria for our study if they were diagnosed with sev eral of the symptoms of PCS or PTSD, such as headache, alternative may have eliminated some error resulting nosed and distinguished. Finally, cumulative blast expo sure simply may not result in injury in the same way as single, large exposures. This may have correlation to the determining long term sequelae. 12,14 Unfortunately, we did not include this vital piece of information as we did not have access to the deployment medical records. Our exposure data may not be an accurate way to predict blast dose to the Soldier. Furthermore, the development of PCS and PTSD may not be as strongly related to blast dose as it is to other injuries or experiences. These observations bring to light some limitations of this study, including the facts that the estimate of blast intensity was not validated independently with physi cal or biomechanical measurements; we were unable to evaluate other combat and noncombat exposures that contribute to PCS and PTSD; we did not have access to longitudinal health records during the deployment; and recorded health histories prior to deployment were not assessed. CONCL US ION Our study provides evidence that blast exposure and particularly being targeted in a blast are predictive of the development of PCS and further, for those targeted more than one time, PCS in conjunction with PTSD. Those in vehicles sustaining heavy battle damage are at an increased risk of being diagnosed with PTSD and PCS in conjunction with PTSD. Finally, Soldiers with previous deployments may be more likely to be Table 5. Sensitivity Analysis of Complex Model. Cumulative Intensity Score PCS CRR (95% CI) PTSD CRR (95% CI) Both CRR (95% CI) >0 2.90 (1.41-5.97) 1.76 (0.83-3.77) 3.19 (0.96-10.6) >1 2.55 (1.35-4.80) 2.28 (1.07-4.89) 3.19 (0.96-10.6) >2 2.30 (1.31-4.03) 1.77 (0.91-3.44) 3.00 (1.13-7.99) >3 2.35 (1.37-4.40) 2.16 (1.11-4.20) 3.67 (1.38-9.77) >4 2.29 (1.37-3.84) 1.69 (0.90-3.16) 2.36 (1.01-5.50) >5 2.61 (1.57-4.35) 1.66 (0.89-3.10) 2.91 (1.25-6.76) >6 2.12 (1.30-3.47) 1.35 (0.71-2.55) 2.12 (0.94-4.76) Table 4. Sensitivity Analysis of Gunner Model. Cumulative Intensity Score PCS CRR (95% CI) PTSD CRR (95% CI) Both CRR (95% CI) >0 2.22 (1.25-3.96) 1.77 (0.89-3.50) 2.08 (0.83-5.20) >1 1.71 (1.04-2.84) 1.14 (0.61-2.13) 0.97 (0.43-2.20) >2 1.90 (1.16-3.12) 1.31 (0.69-2.47) 1.71 (0.76-3.86) >3 1.82 (1.09-3.03) 1.68 (0.87-3.23) 2.32 (1.02-5.27) >4 2.32 (1.39-3.88) 1.69 (0.83-3.43) 2.89 (1.26-6.62) >5 2.63 (1.53-4.52) 1.34 (0.55-3.26) 2.44 (0.94-6.29) >6 2.42 (1.27-4.62) 1.27 (0.41-3.87) 2.20 (0.69-6.99) Table 3. Sensitivity Analysis of Simple Model. Cumulative Intensity Score PCS CRR (95% CI) PTSD CRR (95% CI) Both CRR (95% CI) >0 2.36 (1.34-4.15) 1.61 (0.84-3.09) 2.42 (0.97-6.07) >1 2.02 (1.22-3.32) 1.29 (0.69-2.42) 1.94 (0.86-4.37) >2 2.24 (1.37-3.66) 1.33 (0.68-2.61) 2.09 (0.92-4.75) >3 1.97 (1.13-3.44) 1.24 (0.54-2.85) 2.33 (0.95-5.70) >4 2.19 (1.17-4.09) 1.37 (0.51-3.65) 2.43 (0.87-6.79) >5 1.24 (0.42-3.60) 0.60 (0.09-4.15) 1.00 (0.14-7.05)

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx diagnosed with both PCS and PTSD. According to our data, the development of these diagnoses does not show a linear trend with increasing number of targeted ex posures or increasing blast intensity estimates. We are, therefore, unable to delineate an exposure threshold that, if maintained, may decrease the incidence of PCS/PTSD, and above which commanders and providers may make informed, operational decisions regarding mission risk. RE F ERENCE S 1. MacGregor A, Shaffer R, Corson K, et al. Preva lence and psychological correlates of traumatic brain injury in Operation Iraqi Freedom. J Head Trauma Rehabil 2010;25(1):1-8. 2. Terrio H, Brenner L, Warden D, et al. Traumatic US Army brigade combat team. J Head Trauma Rehabil 2009;24(1):14-23. 3. Ahmed F, Kamnaksh A, Kovesdi E, Long J, Agos ton D. Long-term consequences of single and mul tiple mild blast exposure on select physiological parameters and blood-based biomarkers. Electro phoresis 2013;34(15):2229-2233. 4. Calabrese E, Du F, Garman R, et al. Diffusion ten sor imaging reveals white matter injury in a rat model of repetitive blast-induced traumatic brain injury. J Neurotrauma 2014;31(10):938-950. 5. Elder G, Mitsis E, Ahlers S, Cristian A. Blast-in duced mild traumatic brain injury. Psychiatr Clin North Am 2010;33(4):757-781. 6. Hoge C, McGurk D, Thomas J, Cox A, Engel C, Castro C. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. New Engl J Med 2008;358(5):453-463. 7. Kamnaksh A, Kwon S, Kovesdi E, et al. Neurobe havioral, cellular, and molecular consequences of single and multiple mild blast exposure. Electro phoresis 2012;33(24):3680-3692. 8. Polusny MA, Kehle SM, Nelson NW, Erbes CR, Arbisi PA, Thuras P. Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in National Guard Soldiers deployed to Iraq. Arch Gen Psychiatry 2011;68(1):79-89. 9. Warden D. Military TBI during the Iraq and Afghanistan wars. J Head Trauma Rehabil 2006;21(5):398-402. 10. French L, Parkinson G. Assessing and treating vet erans with traumatic brain injury. J Clin Psychol 2008;64(8):1004-1013. 11. Courtney A, Courtney M. A thoracic mechanism of mild traumatic brain injury due to blast pressure waves. Med Hypotheses 2009;72(1):76-83. 12. Jorge R, Acion L, White T, et al. White matter ab normalities in veterans with mild traumatic brain injury. Am J Psychiatry 2012;169(12):1284-1291. 13. McCrea M, Pliskin N, Yoash-Gantz R, et al. Of role of neuropsychology and rehabilitation psychol ogy in the evaluation, management, and research of military veterans with traumatic brain injury. Clin Neuropsychol 2008;22(1):10-26. 14. Walker W, McDonald S, Ketchum J, Nichols M, sciousness induced by military-related blast expo sure and its relation to postconcussion symptoms. J Head Trauma Rehabil 2013;28(1):68-76. 15. Bryant R. Disentangling mild traumatic brain injury and stress reactions. New Engl J Med 2008;358(5):525-527. 16. Trudeau D, Anderson J, Barton S, et al. Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion. J Neu ropsychiatry Clin Neurosci 1998;10(3):308-313. 17. Wilk J, Herrell R, Wynn G, Riviere L, Hoge C. Mild traumatic brain injury (concussion), posttrau matic stress disorder, and depression in US Sol diers involved in combat deployments: association with postdeployment symptoms. Psychosom Med 2012;74(3):249-257. 18. Meares S, Shores E, Marosszeky J, et al. Mild trau matic brain injury does not predict acute postcon cussion syndrome. J Neurol Neurosurg Psychiatry 2008;79(3):300-306. 19. Sim A, Terryberry-Spohr L, Wilson K. Prolonged recovery of memory functioning after mild trau matic brain injury in adolescent athletes. J Neuro surg 2008;108(3):511-516. 20. Vagnozzi R, Signoretti S, Lazzarino G, et al. Tem poral window of metabolic brain vulnerability to concussion: a pilot 1H-magnetic resonance spec troscopic study in concussed athletes--part III. Neurosurgery June 2008;62(6):1286-1295. AU T H OR S MAJ Saxe is a General Surgery Physician Assistant at the Evans Army Community Hospital, Fort Carson, Colorado. Dr Perdue is the US Public Health Service Chief, Divi and Planning, Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC. ASSOCIATIONS BETWEEN OPERATIONALLY ESTIMATED BLAST EXPOSURES AND POSTDEPLOYMENT DIAGNOSES OF POSTCONCUSSION SYNDROME AND POSTTRAUMATIC STRESS DISORDER

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January March 2015 79 PO S TTR AU M A TIC STRE SS DI S ORDER Although recently there has been much publicity about posttraumatic stress disorder (PTSD) in the national me dia, PTSD is not a new phenomenon. In the last century, PTSD was called war neurosis, soldiers heart, shell shock, 1 combat fatigue and battle fatigue. 2 According to the Diagnostic and Statistical Manual of Mental Disor ders IV (DSM-IV) the diagnostic criteria for PTSD in cludes experiencing or witnessing events that involved actual or perceived death or injury to self or others in which the exposed individual responded with intense fear, horror, or helplessness. 3 Symptoms of PTSD in clude: initial stressor (exposure to a violent event); per sistent re-experiencing of the event while awake or in the form of nightmares; avoidance of stimuli associated with the event; alterations in affect and emotional de tachment; and alterations in arousal and reactivity such as sleep disturbances and hyper-vigilance. The diagno sis of PTSD requires the symptoms remain for a month or longer and the disturbance must cause clinically sig or other important areas of functioning. 3 Posttraumatic stress disorder is a continuous concern for the Departments of Defense (DoD) and Veterans Af fairs (VA), especially for service members associated with combat operations, including their families. How ever, determining the overall prevalence rate of PTSD is not an easy task. In a critical review of the combatrelated PTSD prevalence estimates, the authors report ed a range of 2% to 17% point prevalence rate of US military veterans since the Vietnam War. 4 In a study on service members serving in theater for Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), it was re ported that 14% of the 1,965 survey responders met the criterion for PTSD. 5 If the survey responders are repre sentative of the currently over 2.5 million troops who have been deployed in support of OIF and OEF, 6 this would indicate that approximately 350,000 will have PTSD. All military personnel do not develop PTSD, and many studies have focused on the risk and protective factors to determine methods of protecting those at greatest risk. Factors that have a possible role in the risk of develop ing PTSD include age and education at the time of de ployment, gender, race, early conduct problems, intel ligence, childhood adversity, family history of psychiat ric disorder, pre-deployment psychological and physical health, poor social support after trauma, and personality pathology. 4(pp9-10) To our knowledge, this article is the military sample. TEM P ER A MENT In the 20th century, child psychologists Thomas and Chess studied infant and child development. They stat ed that, Temperament can be equated to the term be havioral style. Each refers to the how rather than the what (abilities and content) or the why (motivations) enological term and has no implications as to etiology or Temperament Dimensions and Posttraumatic Stress Symptoms in a Previously Deployed Military Sample LTC Sandra M. Escolas, MS, USA Hollie D. Escolas, BA AB S TR A CT This study examines the effects of temperament on self-reported posttraumatic stress disorder (PTSD) symp toms from a convenience sample of US military service members (N=559). Previously deployed active duty service members completed anonymous questionnaires that included demographics, temperament, and PTSD measures. This study also examines demographic variables such as age, gender, ethnicity, race, education, and marital status, and service-related variables such as branch, grade, and years of military service for moderating effects. Results suggest a relationship between the temperament dimensions and PTSD symptoms in that the temperament as a predictor of PTSD within a military population and provides the basis for future research in this area.

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80 http://www.cs.amedd.army.mil/amedd_journal.aspx immutability. On the contrary, like other characteristics of the organismwhether it be height, weight, intellec tual competence, or perceptual skillstemperament is and even in the nature as development proceeds. 7(p9) Based on the classic infant temperament styles estab lished by Thomas, Chess, and colleagues, temperament may be viewed as a continuum from very easy to fant temperament which include: (1) activity level; (2) rhythmicity; (3) approach-withdrawal; (4) adaptability; (5) threshold of responsiveness; (6) intensity of reaction; (7) quality of mood; (8) distractibility; and (9) attention span and persistence. These results came from their 1950s New York Longitudinal Study 8 (NYLS). The tem perament dimensions are used to categorize infant tem 7-9 proach responses to new stimuli, high adaptability to change, and mild or moderately intense mood that is preponderantly positive. Slow-to-warm up babies are characterized by a combination of negative responses of mild intensity to new stimuli with slow adaptabil ity after repeated contact...mild intensity of reactions, whether positive or negative, and by less tendency to show irregularity of biological functions. 7 tions, negative withdrawal responses to new stimuli, nonadaptability or slow adaptability to change, and in tense mood expressions which are frequently negative. 7 Results of the NYLS reported 40% of the infants in the 7,9 Temperament is generally considered relatively stable from infancy throughout maturation and adult life. 11-16 Most cur rent temperament researchers would agree with Buss and Plomins (1984) notion that early onto genetic ap pearance, moderate stability, and distinctive biologi of temperament. 17(p14) In essence, temperament can be considered as ones general style of behavior. 15 The theoretical relative stability of temperament estab lishes the connection between the child and adult tem perament literature. Windle and Lerner 15 developed 10 adult temperament dimensions: (1) activity level-general; ibility-rigidity; (5) mood quality; (6) rhythmicity-sleep; (7) rhythmicity-eating; (8) rhythmicity-daily habits; (9) distractibility; and (10) persistence. The principle here is that measuring a persons temperament in adulthood would result in very similar styles to their childhood tempera ment. As with Thomas and Chesss temperament dimen sions, these adult temperament dimensions do not measure performance ability or motivations for behavior but places the emphasis on how people behave. For example, activ ity level-general refers to an overall measure of how much a person moves, whereas activity level-sleep refers to the amount of movement a person has while asleep or in bed. Approach-withdrawal indicates the initial response a per son has when being presented with new people, items, or it takes for a person to accommodate to changes in their environment. Mood quality is the degree to which a per son overtly displays their mood such as smiling or laugh ing. The 3 rhythmicity dimensions for sleeping, eating and daily habits indicate how regular a person is in maintain ing their daily schedules in order to function. The distract ibility dimension indicates the degree to which a person persistence, refers to the amount of time a person will con tinue with a given task or activity. 18 P T S D A ND TEM P ER A MENT A limited but growing number of studies have inves tigated the role of temperament in the development of PTSD and anxiety disorders in children and adult popu lations. Using the terrorist attacks of September 11, 2001, (9/11) as a pivotal event, Lengua and colleagues found preattack anxiety levels, as a measure of temperament, were associated with children reporting a higher level of postattack posttraumatic stress (PTS) symptoms. 19 It was not that children were directly exposed to the 9/11 attacks but that they witnessed the events and heard the commentary on television. Otto and colleagues found that on the day of the attacks adults watched a mean of 8.1 hours of television coverage, and their children watched a mean of 3.0 hours. 20 Results such as these were used to support the belief that children may devel op PTSD through media exposure of a traumatic event. A distinction is made for adults and children; the expo sure to a traumatic event via any visual media is not ap plicable for adults unless work related such as combat 19 Additional studies of traumatic events support the idea least in vulnerable populations such as children. 21 Tem perament is considered to be relatively stable and this sta bility helps to predict how children will manage and react to their environments. 22 For example, children exposed to traumatic domestic violence were found to be more re silient when characterized with an easy temperament. 23 TEMPERAMENT DIMENSIONS AND POSTTRAUMATIC STRESS SYMPTOMS IN A PREVIOUSLY DEPLOYED MILITARY SAMPLE

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January March 2015 81 TH E CU RRENT ST U DY Data from a cross-sectional study was analyzed to exam ine the relationship between temperament and PTSD. MET H OD S Procedure Data were collected from a convenience sample of service members using anonymous self-reporting questionnaires. Demographics information and measures for PTSD and temperament were included. Subjects were recruited from gathering places such as the post or base exchanges and classrooms from Joint Base San Antonio (JBSA), which includes Fort Sam Houston and Lackland Air Force Base in San Antonio, Texas. The subjects completed the volun tary 15 to 20 minute questionnaire and returned it to the study personnel who had provided the questionnaire. The data were collected from summer 2010 to summer 2011. As PTSD rates have been steadily increasing since deploy ments to Iraq and Afghanistan began, we included only previously deployed service members in our subject pool to examine the relationship of temperament dimensions to the development of self-reported PTSD symptoms in this population. Criteria for participation included a deploy ment of at least 30 days, aged 18 years or older, and on active duty at the time the questionnaire was completed. and the anonymous nature of the questionnaire, this study received an exempt determination from the Brooke Army Medical Center Institutional Review Board. Participants The participants included 559 service members recruited from JBSA. The demographics and service-related char acteristics are described in Tables 1 and 2. Demographics include age, gender, ethnicity, race, education, and mari tal status. Service-related characteristics include branch of service, grade, and years of military service. Measures Two measurement tools included in the questionnaire package were the PTSD Checklist-Military (PCLM) 24 and Dimensions of Temperament SurveyRevised (DOTS-R). 15 PCL-M The PCL-M 24 is a 17-item self-report inventory that is widely used in DoD and VA with excellent reliability and validity. The PCL-M assesses the severity of each DSMIV 3 DSM-IV diagnostic criteria for PTSD and is scored on a 1-5 scale (1-not at all; 5-extremely). Previous research on the PCL-M indicated mean scores of 64.2 (SD=9.1) for PTSD subjects and 29.4 (SD=11.5) for non-PTSD subjects. Table 1 Demographics of Study Participants. Number ( N =559) % N Age Group (years) 25 or less 45 8.0% 26-30 126 22.5% 31-40 271 48.5% 41 or over 117 20.9% Gender Male 401 71.7% Female 157 28.1% Ethnicity Hispanic 69 12.3% Non-Hispanic 484 86.6% Race Caucasian/White 358 64.8% African American 107 19.5% Asian/Pacific Islander 33 5.9% Other 48 8.8% Civilian Education Some HS, GED, HS Diploma 20 3.6% Some College, AAS, BA/BS 407 72.8% MA/MS, Professional, PhD 125 22.5% Marital Status Never married 81 14.5% Currently married or living with a partner 378 67.6% Currently separated or divorced 93 16.6% HS-High School; GED-General Educational Development; AAS-Associates Degree; BA/BS-Bachelors Degree; MA/MS-Masters Degree; PhD-Doctorate Degree Table 2. Service Related Characteristics of Study Participants. Number (N=559) %N Branch of Service US Army 345 61.7% US Air Force 206 36.9% US Navy 6 1.1% US Coast Guard 2 0.4% Grade ( combined services ) E1-E4 29 5.2% E5-E7 305 54.6% E8-E9 20 3.6% WO1-WO4 9 1.6% O1-O3 129 23.1% O4-O5 40 7.2% O6above 8 1.4% Years of Military Service 2 or less 8 1.5% 3 to 4 43 7.8% 5 to 7 72 13.1% 8 to 10 113 20.5% 11 to 14 120 21.8% 15 to 20 138 25.0% 21 or more 57 10.3%

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82 http://www.cs.amedd.army.mil/amedd_journal.aspx DOTS-R The DOTS-R 15 is a revision of the initial Dimensions of Temperament Survey developed by Lerner and col leagues 25 to assess temperament factors. The DOTS-R, a 54-item questionnaire, measures 10 adult temperament di mensions: (1) activity level-general; (2) activity level-sleep; quality; (6) rhythmicity-sleep; (7) rhythmicity-eating; (8) rhythmicity-daily habits; (9) distractibility; and (10) per alpha) reported by Windle and Lerner were .84, .89, .85, .78, .89, .78, .80, .62, .81, and .74, respectively, for the 10 listed factors demonstrating acceptable reliability of this instrument. 15,26 Data Analysis Data analysis was conducted using SPSS Version 19 (IBM Corp, 2010). Pairwise deletion was used to con trol for missing data so that the respondent was dropped from the analyses that involved only the variables that have missing values. Linear regressions were used for data analyses using the enter method which enters all analysis was used to determine which temperamental factors would be associated with PTSD scores. All 10 temperament dimensions were entered into the model and regressed on the total PTSD score. The second lin ear regression was conducted in which the temperament factors plus demographics and service-related charac teristics were used to predict PTSD score. RE SU LT S perament factors were entered into a linear regression as independent variables; 4 of the 10 temperament di rigidity, and activity level-general. This regression analy sis determined that temperament dimensions predict 36% of the variance for a PTSD score. Mood quality was found to be the strongest predictor, responsible for 26% of variance in PTSD scores. The remaining rigidity, and activity level-general) only accounted an additional 10% of the variance in the PTSD score. Therefore, mood quality is the best predictor of selfreported PTSD symptoms. Table 3 presents the de scriptive statistics for the temperament dimensions and the PTSD measure. The second regression analysis (Model 2) was con regression equation remained after adding the de mographic and service-related variables. Mood adding the demographic variables and service-related variables. Rhythmicity-sleep and rhythmicity-daily hab its of the temperament dimensions, age and race of the demographic variables, and branch of the service related model. However, the addition of all these variables into the model only increased the variance accounted for by 3%. The regression models are shown in Table 4. COMMENT Using self-report measures, the temperament dimen sions appear to be related to PTSD symptomology. The mood quality temperament dimension was found to be the strongest predictor of self-reported PTSD score fol tivity level-general. The inverse relationship indicates that individuals reporting higher mood quality reported lower PTSD symptom scores. This result is similar to that reported by Miller 27 in that the personality con struct of positive and negative emotionality was related to PTSD. Personality constructs like positive and nega tive emotionality have been found to be closely related hood and infancy, and that these constructs remain stable throughout adulthood. 27 Changes in sleep and restless ness are consistently listed symptoms for PTSD within the DSM-IV. Gellis et al 28 studied sleep disturbances in service members with a positive PCL-C screen for PTSD and found a positive relationship between depression and nightmares with disturbed sleep. Measures of the mood quality dimension, including other temperament factors, have been demonstrated to be relatively stable temperaments and not affective symptoms associated with PTSD. The contrary is plausible however, and further investigations with a within-subjects design of TEMPERAMENT DIMENSIONS AND POSTTRAUMATIC STRESS SYMPTOMS IN A PREVIOUSLY DEPLOYED MILITARY SAMPLE Table 3. Descriptive Statistics for Temperament Dimensions and Posttraumatic Stress Disorder Measure. N Minimum Maximum Mean SD Activity Level General 559 7 28 18.12 4.47 Activity Level Sleep 551 3 16 10.83 3.41 Approach-Withdrawal 559 8 28 18.74 3.47 Flexibility-Rigidity 559 5 20 14.39 3.00 Mood Quality 559 5 28 22.30 4.91 Rhythmicity-Sleep 559 2 24 14.76 4.00 Rhythmicity-Eating 559 3 20 13.14 3.70 Rhythmicity-Daily Habits 559 2 20 11.77 2.95 Distractibility 559 5 20 12.23 2.79 Persistence 559 2 12 8.57 1.65 PTSD Score 547 17 76 30.21 14.33 Valid N listwise 543

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January March 2015 83 preand postdeployment measures of temperament may elaborate the relationship quantitatively. Research suggests that PTSD disposition in the military may be based on predisposing factors including gender, age at trauma, race, education, previous trauma, general childhood adversity, psychiatric history, reported child hood abuse, and family psychiatric history. 29,30 Some certain populations. Others such as general childhood adversity had more uniform predictive effects and pre dicted PTSD more consistently. One limitation of our study is the relatively small sample size and limited military occupational specialties. Our but the ideal population sample would include a larger number of personnel with a variety of occupations to represent the entire spectrum of military members to in clude but not be limited to combat ready infantry, mech anized cavalry, medical personnel, logisticians, and or dinance personnel, among others. Our sample was de rived from installations within Joint Base San Antonio, Texas, where the primary missions are basic training, medical education and training, and health care delivery. A second limitation could result from the use of a selfreport instrument. The use of self-reporting surveys/ screening tools are commonly thought to be biased, however, social science depends on these tools. Brener and colleagues reviewed over 100 stud ies of self-reported questionnaires for validity and determined that they are accurate when individuals under stand the questions and when there is a strong sense of anonymity and little fear of reprisal. 31 Any bias in selfreporting may result from participants completing the questionnaires in non controlled environments, such as at a food court, at home or workspace, ei ther alone or in the presence of others, which may cause reluctance in provid ing honest answers. 32 It is important to note that the DSM-IV has been updated to a newer version (DSM-V 33 ), however, the PTSD mea sure used in this study is based upon the DSM-IV criteria and for consis tency we used the DSM-IV criteria for this study. In our opinion, this does not CONCL US ION Our results indicate the need to increase research in the area of temperament/PTSD to determine if people with certain temperaments may be more vulnerable to PTSD. If this is the case, efforts to develop and provide protec tive/preventative measures before exposure to traumatic situations may be considered. In addition, perhaps the most vulnerable could be assigned to a military occupa perament and occupation, and even minimize exposure to traumatic situations. 7,9 This information is important for the well-being of our military service members and should continue to be studied. FU T U RE DIRECTION S sight into future directions for research into the relation ship between temperament and PTSD. To the authors PTSD within a military sample. Its replication would the variation in PTSD symptoms to control for known moderators and risk factors not measured in the study, such as trauma intensity, peritrauma fear, and combat exposure. 30,32 into account a patients unique temperament when treat ing personnel affected by PTSD. Table 4. Regression Models Predicting Posttraumatic Stress Disorder Score. Model 1 Model 2 Variable B SE B SE (Constant) 58.14 5.57 50.94 7.43 Activity Level General 0.43 0.13 0.13, P <.001 0.44 0.13 0.14, P <.001 Activity Level Sleep 0.79 0.16 0.19, P <.001 0.81 0.16 0.19, P <.001 Approach-Withdrawal -0.05 0.18 -0.01 -0.08 0.18 -0.02 Flexibility-Rigidity -0.78 0.19 -0.16, P <.001 -0.71 0.20 -0.14, P <.001 Mood Quality -0.89 0.12 -0.30, P <.001 -0.84 0.12 -0.28, P <.001 Rhythmicity-Sleep -0.35 0.18 -0.09 -0.44 0.18 -0.12, P <.05 Rhythmicity-Eating -0.17 0.19 -0.04 -0.06 0.19 -0.01 Rhythmicity-Daily Habits -0.45 0.23 -0.09 -0.49 0.23 -0.10, P <.05 Distractibility -0.08 0.21 -0.02 -0.12 0.21 -0.02 Persistence 0.19 0.35 0.02 0.34 0.35 0.04 Age 1.46 0.66 0.09, P <.05 Gender 1.21 1.16 0.04 Race 1.13 0.55 0.07, P <.05 Ethnicity -1.31 1.60 -0.03 Branch of Service -1.79 0.50 -0.13, P <.001 Marital Status 0.91 0.70 0.05 Education -0.18 0.57 -0.02 Rank Combined -0.06 0.34 -0.01 Adjusted R 2 0.357 0.385 F for model ( df ) 31.15(10,532), P <.001 19.37 (18,511), P <.001 B indicates the unstandardized coefficient.

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84 http://www.cs.amedd.army.mil/amedd_journal.aspx ACKNO W LEDGEMENT S This research was supported in part by an appointment to the Student Research Participation Program at the US Army Institute of Surgical Research, administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US De partment of Energy and US Army Medical Research and Materiel Command. We thank Dr James Aden for his help and support on processing the statistics and LTC Mann-Salinas for her help with the revision process. RE F ERENCE S 1. Crocq MA, Crocq L. From shell shock and war neurosis to posttraumatic stress disorder: a history of psychotraumatology. Dialogues Clin Neurosci 2000;2(1):47-55. 2. Shively SB, Perl DP. Traumatic brain injury, shell shock, and posttraumatic stress disorder in the military--past, present, and future. J Head Trauma Rehabil. May-Jun;2012;27(3):234-249. 3. American Psychiatric Association. 309.81 Post traumatic Stress Disorder. In: Diagnostic and Sta tistical Manual of Mental Disorders 4th ed. Wash ington, DC: American Psychiatric Association: 1994:424-429. 4. Richardson LK, Frueh BC, Acierno R. Prevalence estimates of combat-related post-traumatic stress disorder: critical review. Aust N Z J Psychiatry 2010;44(1):4-19. 5. Tanielian T, Jaycox LH, Schell TL, et al. Invisible Wounds: Mental Health and Cognitive Care Needs of Americas Returning Veterans Santa Monica, CA: RAND Corporation; 2008. 6. RAND Corporation. Invisible Wounds of War Project [internet]. 2013. Available at: http://www. rand.org/multi/military/veterans.html. Accessed December 14, 2013. 7. Thomas AT, Chess S. Temperament and Develop ment New York, NY: Brunner/Mazel; 1977. 8. Thomas A, Chess S, Birch HG. Temperament and Behavior Disorders in Children New York, NY: New York University Press; 1968. 9. Thomas A, Chess S. Genesis and evolution of be havioral disorders: from infancy to early adult life. Am J Psychiatry. 1984;141(1):1-9. 10. Thomas A, Chess S, Birch HG. The origin of per sonality. Sci Am. 1970;223(2):102-109. 11. Buss AH, Plomin R. Temperament: Early Develop ing Personality Traits Hillsdale, NJ: L Erlbaum; 1984. 12. Goldsmith HH, Buss AH, Plomin R, et al. Roundta ble: what is temperament? Four approaches. Child Dev. 1987;58(2): 505-529. 13. Rothbart MK, Derryberry D. Development of indi vidual differences in temperament. In: Lamb ME, Brown AL, eds. Advances in Developmental Psy chology Hillsdale, NJ: Erlbaum; 1981:37-86. 14. Green J, Bax M, Tsitsikas H. Neonatal behavior and early temperament: a longitudinal study of Am J Orthopsychiatry. 1989;59(1):82-93. 15. Windle M, Lerner RM. Reassessing the dimensions of temperamental individuality across the life span: the Revised Dimensions of Temperament Survey (DOTS-R). J Adolesc Res. 1986;1:213-230. 16. Saudino KJ. Behavioral genetics and child temper ament. J Dev Behav Pediatr. 2005;26(3):214-223. 17. Zentner M, Bates JE. Child temperament: an inte grative review of concepts, research programs, and measures. Eur J Dev Sci 2008;2(1/2):7-37. 18. Windle M. Revised dimensions of temperament tory factor analysis for adolescent gender groups. Psychol Assess 1992;4(2):228-234. 19. Lengua LJ, Long AC, Smith KI, Meltzoff AN. Pre-attack symptomatology and temperament as predictors of childrens responses to the Septem ber 11 terrorist attacks. J Child Psychol Psychiatry 2005;46(6):631-645. 20. Otto MW, Henin A, Hirshfeld-becker DR, Pol lack MH, Biederman J, Rosenbaum J. Posttrau matic stress disorder symptoms following media exposure to tragic events: impact of 9/11 on chil dren at risk for anxiety disorders. J Anxiety Disord. 2007;21(7):888-902. 21. Martinez-Torteya C, Anne Bogat G, von Eye A, Le vendosky AA. Resilience among children exposed to domestic violence: the role of risk and protective factors. Child Dev. 2009;80(2):562-577. 22. Rothbart M, Bates J. Temperament. In: Eisenberg N, Damon W, Richard LM, eds. Handbook of Child Psychology: Vol. 3, Social, Emotional, and Person ality Development. 6th ed. Hoboken, NJ: John Wi ley & Sons Inc; 2006;99-166. 23. Cloitre M, Morin NA, Linares OL. Childrens re silience in the face of trauma [internet]. New York University Child Study Center; 2010. Available at: http://www.education.com/reference/article/Ref_ Childrens_Resilience/ Accessed December 9, 2014. 24. Weathers FW, Litz BT, Herman DS, Huska JA, Ke ane TM. The PTSD Checklist (PCL): reliability, validity, and diagnostic utility. Abstract presented at: 9th Annual Meeting of the International Society for Traumatic Stress Studies; October 1993; San Antonio, TX. Available at http://www.pdhealth. mil/library/downloads/PCL_sychometrics.doc. Accessed July 10, 2013. TEMPERAMENT DIMENSIONS AND POSTTRAUMATIC STRESS SYMPTOMS IN A PREVIOUSLY DEPLOYED MILITARY SAMPLE

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January March 2015 85 25. Lerner RM, Palerno M, Spiro A III, Nesselroade JR. Assessing the dimensions of temperament individuality across the life span: the dimen sions of temperament survey (DOTS). Child Dev 1982;53(1):149-159. 26. Windle M. Temperament and social support in adolescence: interrelations with depressive symp toms and delinquent behaviors. J Youth Adolesc. 1992;21(1):1-21. 27. Miller MW. Personality and the development and expression of PTSD. PTSD Res Q 2004;15(3):3. Available at: http://www.ptsd.va.gov/professional/ newsletters/research-quarterly/V15N3.pdf. Ac cessed December 18, 2014. 28. Gellis LA, Gehrman PR, Mavandadi S, Oslin DW. Predictors of sleep disturbances in Operation Iraqi Freedom/Operation Enduring Freedom veterans reporting a trauma. Mil Med 2010;175(8):567-573. 29. Trickey D, Siddaway AP, Meiser-Stedman R, Ser pell L, Field AP. A meta-analysis of risk factors for post-traumatic stress disorder in children and ado lescents. Clin Psychol Rev 2012; 32(2):122-138. 30. Boscarino JA, Kirchner HL, Hoffman SN, Sar torius J, Adams RE, Figley CR. The New York PTSD risk score for assessment of psychological trauma: male and female versions. Psychiatry Res 2012;200(2-3):827-834. 31. Brener ND, Billy JO, Grady WR. Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence J Adolesc Health. 2003;33(6):436-457. Cited by: Center for Health and Safety Culture. Validity of Self-Report Survey Data [internet]. January 2011. Available at: http:// www.minnetonka.k12.mn.us/TonkaCares/RwR/ Documents/Validity%20of%20Self%20Report. pdf. Accessed July 24, 2013. 32. Ozer EJ, Best SR, Lipsey TL, Weiss DS. Predic tors of posttraumatic stress disorder and symp toms in adults: a meta-analysis. Psychol Bull. 2003;129(1):52-73. 33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Ar lington, VA: American Psychiatric Association. 2013. AU T H OR S LTC Escolas is Chief, Burns and Trauma Research, US Army Institute of Surgical Research, San Antonio Mili tary Medical Campus, San Antonio, Texas. Ms Hollie Escolas is currently pursuing her Master of Arts in Counseling at theUniversity of Texas at San An tonio. She is a research volunteer at the US Army Insti tute of Surgical Research through the Oak Ridge Insti tute for Science and Education.

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86 http://www.cs.amedd.army.mil/amedd_journal.aspx Anonymous estimates indicate that up to 30% of veterans returning from combat operations in Iraq and Afghani stan meet screening criteria for various psychological problems. 1,2 Fewer than half of Soldiers who meet anony mous screening criteria for a behavioral health problem report these problems during Post-Deployment Health Assessment (PDHA) screening. 3 Furthermore, Soldiers who met anonymous screening criteria for a behavioral report these problems during PDHA screening. problems during non-anonymous screening mandated by the Department of Defense (DoD) are less than half the anonymous estimate. 3 Furthermore, among Soldiers behavioral health problem, less than 10% received treat their return from combat operations. 1 Stigma and barriers to care are 2 factors with empirical support that help explain why Soldiers with behavioral health problems are reluctant to report these problems during DoD-mandated screening. 1,2,4 Stigma concerns Soldier beliefs that others (eg, leaders and/or fellow unit members) might think less of them for seeking treat ment. Barriers to care include Soldier perceptions that certain obstacles make accessing available treatment an appointment). This retrospective evaluation explores anonymous Unit Behavioral Health Needs Assessment (UBHNA) data in order to identify predictors of Soldier willingness to honestly report problems and seek treatment dur ing PDHA screening.* Special emphasis was given to identifying organizational factors that unit leaders and order to encourage honest reporting of mental health problems during an upcoming PDHA screening and subsequent treatment seeking when indicated. MET H OD Periodic use of anonymous surveys to evaluate rates of behavioral health problems is common among deployed units. 5 The UBHNA survey is an anonymous survey manders with combat stress control planning. 6,7 Consist ing of 6 pages that query 7 content areas (ie, demograph ics, deployment experiences, work environment, train ing, behavioral health, family, and survey satisfaction), the UBHNA survey is a compilation of free, open-source scales previously validated on a military population (eg, the 17-item Posttraumatic Stress Disorder Checklist, the 9-item Patient Health Questionnaire for depression). 2,8-10 Key capabilities of the UBHNA include estimates of Soldiers meeting screening criteria for behavioral health problems (ie, depression, posttraumatic stress disorder (PTSD), and suicidal ideation), stigma and barriers to care concerns, and a variety of unit climate characteris tics (eg, leadership, cohesion, mission readiness). Large-sample norms established at 3 different time points (pre-, during-, and postdeployment) for nearly every item on the UBHNA are used as a rough gauge of Predicting Willingness to Report Behavioral Health Problems and Seek Treatment Among US Male Soldiers Deployed to Afghanistan: A Retrospective Evaluation LTC Ronald J. Whalen, MS, USA AB S TR A CT This retrospective evaluation explores anonymous survey data to identify predictors of Soldier willingness to report and seek treatment for behavioral health problems during screening mandated by the Department of Defense (DoD). After controlling for stigma and barriers to care concerns, Soldiers with high (+1SD) combat these symptoms during DoD-mandated screening. Furthermore, Soldiers who perceived that their unit leaders likely to report a willingness to disclose behavioral health problems and seek treatment for the same. Perfor mance improvement considerations are discussed. Restricted access: https://www.rto.wrair.army.mil/bhr.html

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January March 2015 87 unit behavioral health at each phase in the deployment cycle. UBHNA to provide anonymous estimates of behavioral health problems within a particular unit, provide feed back in relation to established norms, and make recom mendations on ways to improve unit behavioral health. Like the Mental Health Advisory Team reports that in formed the creation of the UBHNA, 5,6 this study uses a conceptual framework that is based on the Soldier Adaptation Model (SAM). 11 The SAM consists of 3 do mains: stressors, moderators, and strains. Stressors include workplace conditions that tax the exposure, austere living conditions). Moderators are at titudes and circumstances that increase or decrease the impact of stressors (eg, leadership climate). 12 Finally, strains are potential outcomes (eg, depression, PTSD) following exposure to stressors and moderators. While there is a strong dose-response relationship be tween combat exposure and psychological problems like PTSD, unit leaders have limited ability to moder ate levels of combat exposure. The UBHNA, however, can help unit leaders identify behavioral health inter ventions which are designed to help Soldiers cope with known risk factors (eg, seeking evidenced-based treat ment for PTSD). In late June 2011, the task force commander responsible for approximately 750 Soldiers assigned to an infantry battalion requested a UBHNA survey which was con ducted in July 2011. The unit deployed to Afghanistan in January of 2011 and conducted counterinsurgency op erations in the eastern province from January 2011 until December 2011. This was the second year-long deploy ment to Afghanistan for this unit in 3 years. In Novem ber of 2011, approximately one month prior to PDHA screening, a second iteration of the UBHNA survey was conducted on this same task force by the same 2-man combat stress control team collocated within the units battalion aid station. The study sample consisted of Soldiers assigned to an infantry battalion performing combat operations in Af ghanistan. There were 6 subordinate (company) com mands within the battalion, four of which were infantry companies consisting of approximately 100 Soldiers, a headquarters company with a scout platoon, and a sup port company responsible for meeting the logistic needs of the battalion. Three of 4 infantry companies occupied their own combat outposts within the battalions area of operations, while the battalion staff/headquarters company, logistic support company, and an infantry company all shared a common forward operating base in the eastern region of Afghanistan. Female Soldiers were excluded from this analysis given known gender differences in healthcare utilization rates, 13-16 and too few female participants (n=4). 17 Analysis of the UBHNA survey data was authorized under a protocol approved by the Joint Combat Casualty Research Team, Bagram, Afghanistan. ME ASU RE S Willingness to Honestly Report Behavioral Health Problems and Seek Treatment. Two items were added to the standard UBHNA survey that explored Soldier willingness to honestly report symptoms on an upcom ing PDHA, as well as willingness to seek treatment if screening indicated (or Soldiers believed) they had a behavioral health issue. 3 Using a scale ranging from 1 (strongly disagree) to 5 (strongly agree), Soldiers were asked to indicate how much they agreed with the follow ing statements: I feel comfortable honestly reporting any behavioral health problems during the postdeploy ment screening, and If screening results indicate or I believe I have an ongoing behavioral health issue, I will seek treatment. Combat Exposure. Five items on the UBHNA sur vey query combat exposure levels. Two of the 5 items (How often were you in serious danger of being in jured or killed? and How many times did you engage (never) to 3 (many times). The remaining 3 items were dichotomous (eg, Were you responsible for the death of an enemy combatant?). A dichotomous sum score was Posttraumatic Stress Disorder Checklist (PCL): Anony mous rates of posttraumatic stress disorder (PTSD) were estimated using a cut-off score of 50 or higher on the by researchers within the Veterans Administration. 18 Overall Cronbachs alpha for the PCL have ranged from 0.87 to 0.97 in research conducted across a broad spec trum of trauma-related research. 19 A continuous scale of PCL symptom levels was used for this retrospective Patient Health Questionnaire-8 (PHQ-8): The PHQ-8 cation to the PHQ-9, a validated screen for depression widely used throughout the DoD for both research and clinical purposes. 20-22 Because one item from the PHQ-9 Restricted access: https://www.rto.wrair.army.mil/bhr.html

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88 http://www.cs.amedd.army.mil/amedd_journal.aspx is used to estimate both depres sion and suicidal ideation, the item measuring suicidal ideation was re moved from the scale and used as an independent predictor of will ingness to report behavioral health problems and/or seek treatment (see Suicidal Ideation below). Soldier responses were measured using a scale ranging from 0 (not at all) to 3 (nearly every day). Sum scores were produced using the 8 remaining items of the PHQ-9 Suicidal Ideation (SI): Estimates of SI were taken from a single item on the PHQ-9 (ie, Over the LAST 4 WEEKS, how often have you been bothered bythoughts that you would be better off dead, or of hurting yourself in some way). A scale ranging from 0 (not at all) to 3 (nearly every day) was used to measure Soldier responses. Scores on this item were treated as a con tinuous variable. Stigma: Six items on the UBHNA survey query Soldier perceptions of stigma concerning behavioral healthcare. All stigma items were preceded by the following stem: Rate each of the possible concerns that might affect your deci sion to receive behavioral health counseling or servic es. Soldiers evaluated all 6 items using a scale ranging from 1 (strongly disagree) to 5 (strongly agree). Sample stigma items include: Members of my unit might have Barriers to Care: Four items on the UBHNA survey que ry Soldier perceptions of barriers to care. All items were preceded by the following stem: Rate each of the pos sible concerns that might affect your decision to receive behavioral health counseling or services. Soldiers eval uated all 4 items using a scale ranging from 1 (strongly disagree) to 5 (strongly agree). A composite variable UBHNA Survey Follow-up: Five items were added to the standard UBHNA survey to evaluate Soldier percep tions of unit leader use of the July 2011 UBHNA sur 23,24 All 5 items employed a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Three items queried perceptions of survey-based actions (ie, feedback, action) taken by unit leaders follow ing the July UBHNA survey to im prove the psychological wellbeing of their Soldiers (eg, In the PAST 3 MONTHS: I believe my unit used the July 2011 survey results to iden tify issues for improvement). A sum score was generated across all Linear regression was used to evaluate predictors of Soldier will ingness to honestly report behav ioral health problems during PDHA screening. A series of 3 statistical models were used to predict Soldier willingness to honestly report prob lems during an upcoming PDHA. Model 1 included strain indices for mental health problems (adjusted for rank and combat exposure lev els) which would logically predict the perceived need to report prob lems and/or seek treatment. Model 2 included established moderators of Soldier willingness to report problems and/or seek treatment (eg, stigma), as well as an exploration of rou tine unit climate variables found on the UBHNA (eg, leadership, cohesion, morale) and items added as part of a UBHNA survey follow-up. Finally, Model 3 examined the interaction between combat exposure and PTSD symptoms when predicting Soldier willingness to report problems and/or seek treatment in the event that either differed as a function of this interaction. Soldiers who arrived after July (n=7) or failed to provide an arrival date (n=9) were removed from analysis. All analyses were performed using IBM SPSS (Ver 21). RE SU LT S Table 1 describes the demographic characteristics of this sample. The majority of Soldiers were young males ment (69%). Seventeen percent of Soldiers met criteria for PTSD, 15% reported some level suicidal ideation in the past month, while only 3% met criteria for depres sionrates comparable to duringand postdeployment norms reported elsewhere. 2,3 Among sources of men tal health services received during the past year, 14% Table 1 Demographic Characteristics of Sample. Variable UBHNA No. (%N) (N= 150 ) Age (years) 18-24 81 (54.0) 25-29 40 (27.0) 29 (19.0) No. of prior deployments 0 102 (69.0) 1 41 (28.0) Rank Enlisted 95 (64.0) Noncommissioned officers 42 (28.0) Officers 11 (7.0) Psychological disorders Posttraumatic stress disorder Depression 4 (2.7) Suicidal ideation 22 (14.8) Any problem Source of mental health services received in the past year Mental health professional at a military facility 21 (14.0) General medical doctor at a military facility Military chaplain 16 (10.7) Medic in unit 16 (10.7) Soldier in unit (excluding medic) 22 (14.8) Exact numbers vary due to missing data. PREDICTING WILLINGNESS TO REPORT BEHAVIORAL HEALTH PROBLEMS AND SEEK TREATMENT AMONG US MALE SOLDIERS DEPLOYED TO AFGHANISTAN: A RETROSPECTIVE EVALUATION

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January March 2015 89 of Soldiers sought services from a mental health professional. While representative of US Army infantry battalions, the demographic charac teristics of this sample differs in im portant ways from the sample used to create UBHNA during deploy ment norms; namely, this was an allmale sample of younger, more junior ranking Soldiers relative to the UB HNA sample.* Table 2 presents 2 to the 6 stigma items, 4 barriers to care items, and willingness to re port mental health problems and seek treatment during mandated ings reported elsewhere, 4,20 Soldiers with any behavioral health problem endorse all stigma items and 3 of 4 barriers to care items than Soldiers who screened negative. Unlike pre Soldiers with a current behavioral health problem did not differ in their willingness to honestly report behavioral health problems on the PDHA. 3 Table 3 presents bivariate correlations between outcome and predictor variables. There was a strong (positive) bivariate correlation between willingness to seek treat ment and willingness to report behavioral health prob lems ( r =0.75, P <.001). Weak (positive) correlations exist between perceptions of survey-based action and willing ness to report problems ( r =0.30, P <.01) and seek treat ment ( r =0.23, P <.05). There was no correlation between combat exposure levels and willingness to report prob lems or seek treatment. Depression symptoms (PHQ-8) were weakly (negatively) correlated with willingness to seek treatment ( r =-0.15, P <.01). Neither PTSD symptoms nor SI symptoms were correlated with either outcome. for a series of 3 models predicting willingness to hon estly report behavioral health problems during PDHA screening. Model 1 is the baseline model that accounts for rank; combat exposure; and PTSD (PCL), depres sion (PHQ-8), and SI symptoms, none of which pre dicted willingness to honestly report behavioral health problems. Model 2 introduces individual-level percep tions of stigma, barriers to care, leader actions with re prior treatment from a behavioral health professional in the past year. Results from this model indicate that P port behavioral health problems relative to enlisted Sol diers. Furthermore, Soldiers who perceived that their unit leaders took any action on the July UBHNA sur P <.01). Finally, Model 3 includes a positive interaction between combat exposure and PTSD symptoms (PCL) when predicting willingness to honestly report behavioral health prob P <.05). Figure 1 is a plot of the interac tion between combat exposure and PCL scores when predicting willingness to report problems. Soldiers with high PCL scores did not differ in their willingness to report mental health problems as a function of combat exposure. However, Soldiers with high (+1 SD) combat less willingness to report behavioral health problems. Table 2 Stigma, Willingness to Honestly Report Behavioral Health Problems and Seek Treatment (N= ). Survey Item Any Problem 2 P I dont know where to get help. Negative (n= 94 ) 8.54 .074 Positive (n= ) I dont have adequate transportation. Negative (n= 94 ) 15.16 .004 Positive (n= ) It is difficult to schedule an appointment. Negative (n= 94 ) 12.85 .012 Positive (n= ) There would be difficulty getting time off work for treatment. Negative (n= 94 ) 16.46 .002 Positive (n= ) It would harm my career. Negative (n= 94 ) .000 Positive (n= ) Members of my unit might have less confidence in me. Negative (n= 94 ) .000 Positive (n= ) My unit leadership might treat me differently. Negative (n= 94 ) 19.67 .000 Positive (n= ) I would be seen as weak. Negative (n= 94 ) .000 Positive (n= ) My visit would not remain confidential. Negative (n= 94 ) .000 Positive (n= ) My leaders discourage the use of behavioral health services. Negative (n= 94 ) 24.58 .000 Positive (n= ) I feel comfortable honestly reporting any behavioral health problems during the postdeployment screening. Negative (n= 94 ) .256 Positive (n= ) If screening results indicate or I believe I have an ongo ing behavioral health issue, I will seek treatment. Negative (n= 94 ) 6.58 .160 Positive (n= ) Data exclude missing values, because not all respondents answered every question. Any problem includes posttraumatic stress disorder, depression or suicidal ideation. Restricted access: https://www.rto.wrair.army.mil/bhr.html

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90 http://www.cs.amedd.army.mil/amedd_journal.aspx ings for willingness to seek treatment if PDHA screen ing indicates (or Soldiers believed) they had a behavioral health problem. Beginning with Model 1, only combat P <.05) was negatively correlated with willingness to seek treatment. After including stigma, barriers to care, prior treatment from a behav ioral health professional, and perceptions of any leader P <.05) were enlisted Soldiers. Conversely, Soldier perceptions that unit leaders took any survey-based action was positively P <.01). Finally, the interaction between combat expo COMMENT dose-response relationship between combat exposure and behavioral health problems like PTSD. When eval uating the interaction between combat exposure and Table Correlation Matrix for all Outcome and Predictor Variables (N= ). a Range M SD RPT WTX CBT PCL PHQ8 SI STG BTC ACT MHP RPT Willing to Report Problems 1-5 1.10 1.00 WTX Willing to Seek Treatment 1-5 0.99 0.75 b 1.00 CBT Combat Exposure 0-5 0.95 -0.11 -0.18 1.00 PCL PTSD Symptoms 17-85 14.64 0.02 -0.04 0.46 1.00 PHQ8 Depression Symptoms 0-24 7.76 5.49 -0.09 -0.15 c 0.51 0.71 b 1.00 SI Suicidal Ideation 0-4 0.24 0.64 0.06 -0.00 0.41 c 0.46 b 1.00 STG Stigma 14.81 6.65 -0.09 -0.16 0.41 0.44 b 0.51 c b 1.00 BTC Barriers to Care 4-20 7.75 d -0.10 0.29 c 0.41 d 0.25 0.64 b 1.00 ACT Visible Action 0-12 4.66 2.81 c d b -0.14 -0.21 -0.01 1.00 MPH Mental Health Professional e 0-1 NA NA 0.02 0.10 0.16 c 0.16 0.12 0.09 -0.04 -0.20 1.00 a Data exclude missing values, because not all respondents answered every item. b P <. 001 c P <. 01 d P <. 05 e Dichotomous variable: 1 =Yes (n= 21 ) indicates received services from a mental health professional at a military facility in the Past Year ; 0 =No (n= ). Table 4. Standardized Linear Regression Findings for Willingness to Report Behavioral Health Problems (N= 120 ) Willingness to Honestly Report Behavioral Health Problems Variable Est SE t P Est SE t P Est SE t P Model 1 ( R 2 =0 .07 F 6 = 1.42 P = .21 ) Intercept -0.08 -0.64 .521 -0.15 -0.21 -1.61 .110 Noncommissioned officer 0.22 0.58 .565 0.16 0.22 .469 0.17 0.21 0.82 .416 Officer 0.71 0.44 1.62 .108 0.92 2.14 1.01 0.42 .019 Combat exposure -0.20 0.11 -1.77 .080 -0.18 0.12 -1.61 .111 -0.19 0.11 -1.69 .094 Posttraumatic stress symptoms (PCL) 0.02 0.01 .106 0.02 0.01 1.69 0.01 0.01 1.42 .160 Depression symptoms (PHQ -8 ) -0.05 -1.72 .088 -0.04 .190 -1.19 Suicidal ideation 0.17 0.19 0.90 0.21 0.19 1.11 .268 0.24 0.19 1.26 .210 Model 2 ( R 2 =0 .10 F 4 109 = 2.16 P = .05) Stigma -0.01 0.02 -0.52 -0.01 0.02 -0.57 .569 Barriers to care 0.02 0.04 0.58 .566 0.01 0.04 Any survey based action 0.12 0.04 .001 0.12 0.04 .001 Mental health treatment (Past Year) 0.28 0.29 0.98 0.27 0.28 0.97 Model ( R 2 = 0 .04 F 1 120 = P = .05) Combat Exposure X PCL 0.01 0.01 2.11 PHQ-8 indicates Patient Health Questionnaire-8. PCL indicates postraumatic stress disorder checklist PREDICTING WILLINGNESS TO REPORT BEHAVIORAL HEALTH PROBLEMS AND SEEK TREATMENT AMONG US MALE SOLDIERS DEPLOYED TO AFGHANISTAN: A RETROSPECTIVE EVALUATION

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January March 2015 91 PTSD symptoms, we see that Soldiers willingness to report behavioral health problems increases as both combat exposure and PTSD symptoms increase. However, Soldier willingness to seek treatment for a be ing varied only as a function of combat exposureas exposure levels increased, willingness to seek treatment decreased. Clearly, Soldiers weighted other factors as more im portant than behavioral health symptoms levels when contemplating their willingness to seek treatment. The Soldier Adaption Model continues to have conceptual relevance here, in that it allows researchers to explore possible moderators of combat exposurewillingness to seek treatment relationship. Soldiers who perceived that their unit leaders took visible action on prior UB report behavioral health problems during PDHA screen ing; so too for willingness to seek treatment if PDHA screening indicated (or Soldiers believed) they had a to improve the (psychological) command climate of their do perceptions of survey-based actions predict Soldier willingness to participate in future UBHNA surveys, 24 survey-based actions by unit leaders appears to encour age both honest reporting and treatment seeking among their subordinates. Given the nonrandom (convenience) sampling methods may not generalize beyond this unit. Furthermore, no attempt was made to verify whether unit leaders actu ally had taken survey-based action in response to the July UBHNA survey. Finally, these data did not allow for assessment of actual reporting during PDHA relative to Soldier intentions to report captured by the November UBHNA. examine the relative contribution of various forms of UBHNA survey follow-up (eg, feedback, problem identi ness to report problems and/or seek treatment. Finally, the ability to track actual treatment-seeking would add an important element missing in this retrospective study. ACKNO W LEDGEMENT This study was approved by the Joint Combat Casualty Research Team, Bagram, Afghanistan. RE F ERENCE S 1. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA 2006;295(9):1023-1032. 2. Hoge CW, Castro CA, Messer SC, McGurk D, Cot ting DI, Koffman RL. Combat duty in Iraq and Af ghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351(1):13-22. Table 5. Standardized Linear Regression Findings for Willingness to Report Behavioral Health Problems (N= 120 ) Willingness to Seek Treatment for a Behavioral Health Problem Variable Est SE t P Est SE t P Est SE t P Model 1 ( R 2 =0 .10 F 6 = 2.04 P = .07 ) Intercept -0.11 0.11 -0.98 -0.20 0.11 -1.72 .088 -0.24 0.12 -2.08 .040 Noncommissioned officer 0.21 0.19 1.06 .292 0.22 0.19 .260 0.19 1.21 Officer 0.75 1.97 .052 0.90 2.40 .018 0.97 2.57 .011 Combat exposure 0.10 -0.20 0.10 -1.95 .054 -0.20 0.10 -2.01 .047 Posttraumatic stress symptoms (PCL) 0.01 0.01 1.42 .159 0.01 0.01 1.12 .265 0.01 0.01 0.89 Depression symptoms (PHQ -8 ) -0.04 0.02 -0.02 -0.80 .426 -0.02 -0.69 Suicidal ideation 0.01 0.17 0.05 .964 0.02 0.17 0.15 .885 0.04 0.17 0.25 .802 Model 2 ( R 2 =0 .08 F 4 109 = P < .05) Stigma -0.01 0.02 -0.46 .648 -0.01 0.02 -0.50 .622 Barriers to care -0.00 -0.10 .918 -0.01 .760 Any survey based action 0.09 2.76 .007 0.09 2.75 .007 Mental health treatment (Past Year) 0.49 0.25 1.95 .054 0.48 0.25 1.94 .055 Model ( R 2 = 0 F 1 120 = 4.12 P < .05) Combat Exposure X PCL 0.01 0.01 1.69 .095 PHQ-8 indicates Patient Health Questionnaire-8. PCL indicates postraumatic stress disorder checklist

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92 http://www.cs.amedd.army.mil/amedd_journal.aspx 3. Warner CH, Appenzeller GN, Grieger T, et al. Im portance of anonymity to encourage honest report ing in mental health screening after combat deploy ment. Arch Gen Psychiatry 2011;68(10):1065-1071. 4. Kim PY, Thomas JL, Wilk JE, Castro CA, Hoge CW. Stigma, barriers to care, and use of mental health services among active duty and Nation al Guard Soldiers after combat. Psychiatr Serv 2010;61(6):582-588. 5. Bliese PD, Adler AB, Castro CA. Research-based preventive mental health care strategies in the mili tary. In: Adler AB, Bliese PD, Castro CA, eds. De ployment Psychology: Evidence-based Strategies to Promote Mental Health in the Military Wash ington, DC: American Psychological Association; 2011:chap 4. 6. Cox AL, Castro CA. The mental health needs as sessment. In: Human Dimensions in Military Oper ation: Military Leaders Strategies for Addressing Stress and Psychological Support Brussels, Bel gium: NATO Science and Technology Organiza tion; 2006. Available at: http://ftp.rta.nato.int/pub lic//PubFullText/RTO/MP/RTO-MP-HFM-134/// MP-HFM-134-07.pdf. Accessed December 30, 2014. 7. Army Field Manual 6-22.5: Combat and Operation al Stress Control Manual for Leaders and Soldiers Washington, DC: US Dept of the Army; 2009. 8. Britt TW. The stigma of psychological problems in a work environment: evidence from the screening of service members returning from Bosnia. J Appl Soc Psychol. 2000;30(8):1599-1618. 9. Bliese PD, Wright KM, Adler AB, Cabrera O, Cas tro CA, Hoge CW. Validating the primary care posttraumatic stress disorder screen and the post traumatic stress disorder checklist with Soldiers returning from combat. J Consult Clin Psych. 2008;76(2):272-281. 10. Prescott MR, Tamburrino M, Calabrese JR, et al. Validation of lay-administered mental health as sessments in a large Army National Guard cohort. Int J Methods Psychiatr Res 2014;23(1):109-119. 11. Bliese PD, Castro CA. The Soldier Adaptation Model (SAM): applications to peacekeeping re search. In: Britt TW, Adler AB, eds. The Psychol ogy of the Peacekeeper: Lessons from the Field Westport, CT: Praeger Press; 2003:185-203. 12. Harmon SC, Hoyt TV, Jones MD, Etherage JR, Okiishi JC. Postdeployment mental health screen ing: an application of the soldier adaptation model. Mil Med 2012;177(4):366-373. 13. Mackenzie CS, Gekoski WL, Knox VJ. Age, gen der, and the underutilization of mental health ser Ag ing Ment Health. 2006;10(6):574-582. 14. Luxton DD, Skopp NA, Maguen S. Gender dif ferences in depression and PTSD symptoms following combat exposure. Depress Anxiety 2010;27(11):1027-1033. 15. Maguen S, Cohen B, Cohen G, Madden E, Berten thal D, Seal K. Gender differences in health ser vice utilization among Iraq and Afghanistan veter ans with posttraumatic stress disorder. J Womens Health (Larchmnt) 2012;21(6):666-673. 16. Maguen S, Ren L, Bosch JO, Marmar CR, Seal KH. Gender differences in mental health diagno ses among Iraq and Afghanistan veterans enrolled in Veterans Affairs health care. Am J Public Health 2010;100(12):2450-2456. 17. Whalen RJ. Promoting survey-based action by U.S. Army unit leaders in Afghanistan: a case study. Mil Behav Rev. In press. 18. Weathers FW, Litz BT, Herman DS, Huska JA, Ke ane TM. The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at: 9th Annual Meeting of the International Society for Traumatic Stress Studies; October 1993; San An tonio, TX. Available at: http://www.pdhealth.mil/ library/downloads/pcl_sychometrics.doc. Accessed December 30, 2014. 19. Keen SM, Kutter CJ, Niles BL, Krinsley KE. Psychometric properties of the PTSD checklist in a sample of male veterans J Rehabil Res Dev. 2008;45(3):465-474. 20. Hoge CW, Castro CA, Messer SC, McGurk D, Cot ting DI, Koffman RL. Combat duty in Iraq and Af ghanistan, mental health problems, and barriers to care. N Engl J Med. 2004;351(1):13-22. 21. Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment out comes with the patient health questionnaire-9. Med Care 2004;42(12):1194-2001. 22. Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be car ried out over the telephone? J Gen Intern Med 2005;20(8):738-742. 23. Thompson LF, Surface EA. Promoting favorable attitudes toward personnel surveys: the role of fol low-up. Mil Psychol 2009;21(2):139-161. 24. Whalen RJ. Promoting favorable attitudes toward (behavioral health) surveys: the role of follow-up revisited. Mil Psychol In press. AU T H OR LTC Whalen is an Assistant Professor, Counseling Ser vices, Department of Family Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland PREDICTING WILLINGNESS TO REPORT BEHAVIORAL HEALTH PROBLEMS AND SEEK TREATMENT AMONG US MALE SOLDIERS DEPLOYED TO AFGHANISTAN: A RETROSPECTIVE EVALUATION

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January March 2015 93A 63-year-old female with stage I poorly differentiated ductal carcinoma of the left breast, tumor tissue positive for both estrogen and progesterone receptors, was treat ed with lumpectomy followed by 4 cycles of adriamycin and cyclophosphamide. Following a course of adjuvant radiation, she was started on hormonal therapy with an aromatase inhibitor, anastrozole. After 18 months of hormonal therapy, the patient developed recurrent hotpartially relieved with venlafaxine. She also developed recurrent atypical chest pain and mid-epigastric pain, occurring intermittently during her treatment, several of this complaint, she underwent a thorough cardiac workup, including a gated exercise treadmill test with thallium based nuclear medicine imaging showing a normal electrocardiogram, normal ejection fraction, but with imaging concerning for anterolateral ischemia. A follow-up left heart catheterization was consistent with moderate one-vessel coronary artery disease involving artery. Cardiology felt this was not contributing to her chest pain and no intervention was undertaken. As the initial episode of chest pain occurred shortly after start ing alendronate for osteopenia, her treating physicians believed they may be related and changed this medica tion to intravenous zoledronic acid. Despite resolution of her symptoms for a few weeks, her symptoms returned. She was then evaluated by gastroenterology and a thor esophageal and gastric biopsies, abdominal imaging including ultrasound, computed tomography, and upper endoscopy were all normal. She was treated empirically with dicyclomine and omeprazole. Her symptoms worsened with new complaints of dys phagia along with continued vasomotor symptoms. She underwent a barium swallow showing a delay at the aor tic arch and distal esophagus; repeat upper endoscopy tation was performed and she was started on empiric medical treatment for esophageal spasms with a calcium channel blocker and as needed sublingual nitroglycerin. tion regimen, but never totally resolved. Approximately one year later, she had a syncopal episode with a repeat unremarkable cardiac workup including electrocardio gram, transthoracic echocardiogram, and holter monitor, and the event was attributed to vasovagal syncope. Her ued intermittently with further workup unremarkable including a negative HIDA scan and negative repeat upper endoscopy. A gastric emptying scan did reveal agents failed to improve her symptoms. Four years after her initial complaints of intermittent atypical chest pain, abdominal pain, and vasomotor ing 2.3cm by 2.3 cm soft tissue mass noted within the mesentery adjacent to the duodenum with internal calci tant vasomotor symptoms, the diagnosis of carcinoid syndrome was entertained. A subsequent serum chro mogranin A was elevated at 52 ng/ml (reference normal <34 ng/ml) and a 24-hour urine 5-HIAA was elevated at focal hypermetabolic activity at the cecum without a diotracer uptake in the soft tissue mass adjacent to the duodenum, a new liver lesion with uptake, and a single focus of uptake within the mediastinum without a clear anatomic correlate. She underwent a right hemicolec metastatic carcinoid tumor in the distal ileum, mesoap pendix, and liver. Within one month after resection, she developed recur mogranin A levels were 159.2 ng/ml. Further workup with a postoperative octreoscan showed a new liver A Heart Gripping Case: Carcinoid Heart Disease C apt John P. Magulick, MC, USAF M aj Frederick L. Flynt, MC USAF

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94 http://www.cs.amedd.army.mil/amedd_journal.aspx lesion with radiotracer uptake and continued mediasti nal uptake without a clear anatomic correlate. A gated coronary arteries, shown in Figures 1 and 2, with no dis cernible tissue plane between the mass and the ventricle. these coronary arteries as well, with apparent continuity with the myocardium. She was evaluated by cardiotho racic surgery at our institution and this lesion was felt to be unresectable. She sought a second opinion at an outside institution and surgical resection of the tumor and her chromogranin levels declined. She has been fol Carcinoid tumors are a heterogeneous group of neu roendocrine tumors whose clinical characteristics and behavior vary based on the primary site of origin, as each is derived from different precursor cells. Based the small bowel or appendix, and 80% of small bowel primary carcinoids are found in the ileum, as in our patient. 1 tumors commonly present with vague abdominal com plaints as they must grow quite large to cause obstruc tive symptoms, and diagnosis is often delayed for years. Hence, the majority of patients present with metastases at diagnosis, most commonly to the liver and regional lymph nodes. Our patient presented in a similar fashion, with epigastric abdominal pain for several years prior to being diagnosed with metastatic disease. Carcinoid syndrome, characterized by intermittent 7% of carcinoid tumors originating in the small bowel. 2 Carcinoid heart disease, occurring in more than 50% of patients with carcinoid syndrome, 3,4 usually manifests as right heart failure and valvular regurgitation second portant to note cardiac metastases are included in the spectrum of carcinoid heart disease. Cardiac metastases are rare, though when they occur, carcinoid syndrome or metastatic disease to the liver is present a majority A HEART GRIPPING CASE: CARCINOID HEART DISEASE Figure 1 CT Coronary showing a 1.5 cm soft tissue mass splaying the left branch coronary arteries.

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January March 2015 95 of the time. In our review of the literature, only slightly more than 20 cases of cardiac metas tases were reported since 1980, the majority originating from the ileum. A case series of 74 patients with carcinoid by Pellika et al. found 3 (4%) patients had metastases to the heart, all of which originated from the ileum and were as sociated with carcinoid syndrome. 5 In another case series by Pandya et al, of 11 patients with myocardial metastases, 9 (82%) had ileal pri mary tumors, and all 11 had hepatic metastases and carcinoid syndrome. 6 cardiac metastases were found, both presenting as carcinoid syndrome and found to have small bowel primary tumors in the presence of exten sive metastasis, including the heart. 7,8 Several cases of carcinoid heart disease without valvu lar involvement have been documented. Overall, these cases are similar to our case with respect to the extensive metastases and ileal primary, though this is one of only 2 cases presenting with angina. Cardiac metastases can also occur in the absence of he patic metastases as noted in 4 case reports, though only one originated from the small bowel. In one case, a carci noid tumor of the heart was discovered incidentally on a found to have a pancreatic mass 6 months later, which was thought most likely to be the primary. 9 no manifestations of carcinoid syndrome or evidence of liver metastases. Another presented with symptoms of carcinoid syndrome and was found to have cardiac me tastases along with a mass in the pancreatic head. 10 hepatic involvement was discovered based on imaging with known bronchial carcinoid, status post resection, who presented with symptoms of heart failure and was with carcinoid tumor in the absence of valvular disease or hepatic metastases. 11 Another case is one of a patient with appendiceal carcinoid who developed cardiac arrest of the a patient with myocardium. 12 One case describes carcinoid heart disease involving the interventricular septum, presenting with palpitations and paroxysmal 13 Finally, one case describes a patient with metastatic carcinoid inducing coronary vasospasm 14 Based on the results of our literature review, cardiac metastases are most common in the presence of small bowel carcinoid tumors and hepatic metastases, though cardiac metastases without hepatic involvement have been demonstrated, and they may be more common than what is reported. It is also important to recognize cardiac metastases can occur in the absence of carcinoid syndrome, and as the sole manifestation of carcinoid heart disease. Furthermore, these metastases can cause symptoms of heart failure in the absence of valvular disease, cardiac arrest, arrhythmias, or angina by mass effect, as noted in our case. Hence, while cardiac me tastases are rare in patients with carcinoid tumor, they should be considered in the differential for any patient presenting with cardiac-related complaints and a history of carcinoid tumor. RE F ERENCE S 1. Modlin IM, Sandor A. An analysis of 8305 cases of carcinoid tumors. Cancer 1997;79:813-829. 2. stoss AH. Life history of the carcinoid tumor of the small intestine. Cancer 1961;14:901-912. 3. lationship of circulating vasoactive substances to ultrasound-detectable cardiac abnormalities. Cir culation 1988;77(2):264-269. 4. cinoid heart disease: current understanding and future directions. Am Heart J 2014;167(6):789-795. 5. Carcinoid heart disease. Clinical and echocar diographic spectrum in 74 patients. Circulation 1993;87:1188-1196. Figure 2. 3D CT Coronary showing a 1.5 cm soft tissue mass splaying the left

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96 http://www.cs.amedd.army.mil/amedd_journal.aspx 6. wards WD, Schaff HV, Connolly HM. Metastatic carcinoid tumor to the heart: echocardiographicpathologic study of 11 patients. J Am Coll Cardiol 2002;40:1328-1332. 7. Metastatic Cardiac Carcinoid. Tex Heart Inst J 2007;34:132-133. 8. vular myocardial involvement in metastatic carci noid disease. Postgrad Med J 1996;72:751-752. 9. Hennington MH, Detterbeck FC, Szwerc MF, J Surg Oncol 1997;66:264-266. 10. derer M. Case 2: myocardial metastases from a car cinoid tumor. J Clin Oncol 2000;18(7):1596-1597. 11. a bronchial carcinoid: report of a case presenting with diffuse thickening of the left ventricular wall. J Clin Pathol 2004;57:778-779. 12. case of intra-cardiac metastasis from an appendi ceal carcinoid tumour without liver metastases. Int J Colorectal Dis 2009;24:993-994. 13. unusual case of metastatic carcinoid tumor in the interventricular septum. J Cardiovascular Med 14. static carcinoid disease inducing coronary vaso spasm. Tex Heart Inst J 2012;39(1):76-78. AU T H OR S Maj Flynt is Associate Program Director, Hematology/ Medical Oncology, San Antonio Uniformed Services LtCol Steel is Program Director, Cardiology, San Anto cal Oncology, San Antonio Uniformed Services Health A HEART GRIPPING CASE: CARCINOID HEART DISEASE

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January March 2015 97 Evaluation of the Anxiolytic Effects of Asiatic Acid, a Compound from Gotu kola or Centella asiatica, in the Male Sprague-Dawley Rat Valdivieso DA, Kenner C, Lathrop K, Lucia A, Stailey O, Bailey H, Padrn G, Johnson AD, Ceremuga TE US Army Graduate Program in Anesthesia Nursing Purpose: Participants: Methods: PM and 9 PM Results: Conclusion: Value/Relevance: Abstracts of Podium Presentations from the 4th Annual Academy of Health Sciences Graduate School Research Day Presentation of this abstract was selected as the best of the podium presentations at the 4th Annual Academy of Health Sciences Graduate School Research Day.

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98 http://www.cs.amedd.army.mil/amedd_journal.aspx Patient-Centered Medical Home Models and the Impact on Primary Care Practice within the Veterans Health Administration Tansey KA US Army-Baylor University Graduate Program in Health and Business Administration Purpose/Hypothesis: Participants/Data Description: Design/Methods/Materials: Findings/Results: Conclusions: Value/Relevance: ABSTRACTS OF PODIUM PRESENTATIONS FROM THE 4 TH ANNUAL ACADEMY OF HEALTH SCIENCES GRADUATE SCHOOL RESEARCH DAY Presentation of this abstract was selected for third place among the podium presentations at the 4th Annual Acad emy of Health Sciences Graduate School Research Day. Prospective Musculoskeletal Injury Rates Among Different Categories of Soldiers US Army-Baylor University Doctoral Program in Physical Therapy Journal of Sports and Orthopaedic Physical Therapy Presentation of the above cited abstract was selected for second place among the podium presentations at the 4th Annual Academy of Health Sciences Graduate School Research Day.

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January March 2015 99 Long-term Outcomes Among Patients Enrolled in Pre-diabetes Management With Registered Dietitians at a Large Academic Military Teaching Hospital Brooke Army Medical Center Purpose/Hypothesis: Participants/Data Description: Design/Methods/Materials: Findings/Results: Conclusions: Value/Relevance:

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100 http://www.cs.amedd.army.mil/amedd_journal.aspx Implications of Early and Guideline Adherent Physical Therapy for Low Back Pain on Utilization and Costs US Army-Baylor University Doctoral Program in Physical Therapy Purpose/Hypothesis: Participants/Data Description: Design/Methods/Materials: Findings Results: Conclusions: Value/Relevance: Social Media: How Hospitals Use it and Opportunities for Future Use US Army-Baylor University Graduate Program in Health and Business Administration Journal of Healthcare Management A Prospective Review of a Large Military Cohort Office of The Surgeon General of the Army Journal of Sports and Orthopaedic Physical Therapy ABSTRACTS OF PODIUM PRESENTATIONS FROM THE 4 TH ANNUAL ACADEMY OF HEALTH SCIENCES GRADUATE SCHOOL RESEARCH DAY

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January March 2015 101 The poster was selected as best of the presentations as part of the 4th Annual Research Day held December 10, 2014, at the Graduate School, Academy of Health Sciences, AMEDD Center & School, Joint Base San Antonio Fort Sam Houston, Texas.

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102 http://www.cs.amedd.army.mil/amedd_journal.aspx The poster selected for second place among the presentations as part of the 4th Annual Research Day held December 10, 2014, at the Graduate School, Academy of Health Sciences, AMEDD Center & School, Joint Base San Antonio Fort Sam Houston, Texas. WINNING POSTERS PRESENTED AT THE 4 TH ANNUAL ACADEMY OF HEALTH SCIENCES GRADUATE SCHOOL RESEARCH DAY

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January March 2015 103 The poster selected for third place among the presentations as part of the 4th Annual Research Day held December 10, 2014, at the Graduate School, Academy of Health Sciences, AMEDD Center & School, Joint Base San Antonio Fort Sam Houston, Texas.

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104 http://www.cs.amedd.army.mil/amedd_journal.aspx The headquarters and primary instructional facility of the Army Medical Department Center and School, Joint Base San Antonio Fort Sam Houston, Texas.

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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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