Citation
U.S. Army Medical Department journal

Material Information

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

Subjects

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

Notes

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

Record Information

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

Related Items

Preceded by:
Journal of the US Army Medical Department.

UFDC Membership

Aggregations:
Digital Military Collection

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PUBLIC HEALTH: THE CORNERSTONE OF A SYSTEM FOR HEALTH OctoberDecember 20162014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools in Harris County and the City of Houston, Texas ................................................. 1Yvonne H. Randle; Cheryl Battle Freeman; Monique Jackson; Martin Reyna, MS; Mustapha Debboun, PhD, BCEA Multiagency Approach to Reducing West Nile Virus Risk in Richmond County, Georgia, in 2015 .......9Rosmarie Kelly, PhD, MPH; Fred Koehle; Oscar P. Flite III, PhD; R. Chris Rustin, DrPH, MS, REHSProtection of Military Personnel Against Vector-Borne Diseases: A Review of Collaborative Work of the Australian and US Military Over the Last 30 Years ......................................... 14Stephen P. Frances, PhD; Michael D. Edstein, PhD; Mustapha Debboun, PhD, BCE; G. Dennis Shanks, MDEmerging Tick-borne Rickettsia and Ehrlichia at Joint Base Langley-Eustis, Fort Eustis, Virginia .........22Melissa K. Miller, MS; Ju Jiang; Melissa Truong; Tamasin Yarina; et alHoney Bee Swarms Aboard the USNS Comfort: Recommendations for Sting Prevention, Swarm Removal, and Medical Readiness on Military Ships ........................................ 29LCDR James C. Dunford, MSC, USN; CDR Karl C. Kronmann, MC, USN; et alMortality From Fungal Diseases in the US Air Force From 1970 to 2013 ..............................38Richard K. Kugblenu, MPH; Will K. Reeves, PhD, MS of Norovirus in a Population Deployed to Southwest Asia? ....................................... 42LTC Kip R. Thompson, MS, USAR; MAJ Eric C. Mossel, MS, USAR; et alHearing Loss and Tinnitus in Military Personnel with Deployment-Related Mild Traumatic Brain Injury ..52Stephanie J. Karch, AuD, PhD; LTC Jos E. Cap-Aponte, SP, USA; LTC D. Scott McIlwain, SP, USA, et alGoing GLP: Conducting Toxicology Studies in Compliance with Good Laboratory Practices .............64LTC Erica Eggers Carroll, VC, USAAn Expression of Change: Breastfeeding in the Military ............................................70Joseph B. Topinka, JD, MHA, MBA; Linda R. Turner, MLS; Kim Lee, PT, PhD; MAJ Jodi Brown, AN, USAChemical Weapons Exposures in Iraq: Challenges of a Public Health Response a Decade Later .........75Coleen Baird, MD, MPH; MAJ Raul Mirza, MC, USA; Jessica Sharkey, MPH; Ron Teichman, MD, MPH; et alBridging the Gap Between Burn Pits and Waste-to-Energy Technology: Safe and Effective Waste Management in Contingency Operations ................................ 85Animal-Assisted Health and the Performance Triad ................................................99MAJ M. Todd French, VC, USAService Animals: A New Legal Dimension Within the US Military ...................................108Joseph B. Topinka, JD, MHA, MBA, LLM; Jack Nichols, JD; Matthew Brooks, PhDSpurgeon Neel Annual Writing Award Top EssaysGrace Under Fire: The Army Nurses of Pearl Harbor, 1941 ......................................112Gwyneth R Milbrath, RN, MSN, MPH Modernization of the US Army Medical Department ........................................ 118Justin Barr, MD J OURNAL THE UNITED STATES ARMY MEDICAL DEPARTMENT

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J OURNALA Prof essional Publication of the AMEDD CommunityTHE UNITED STATES ARMY MEDICAL DEPARTMENTOnline issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspxOctoberDecember 2016 US Army Medical Department Center & School PB 8-16-10/11/12 The Army Medical Department Journal [ISSN 1524-0436] is published 3630 Stanley RD STE B020478234-6100. The Army Medical Department Journal are listed and Journals CORRESPONDENCE: (210) 221-6301, DSN 471-6301DISCLAIMER: The AMEDD Journal in the AMEDD Journal AMEDD Journal CONTENT: AMEDD Journal OFFICIAL DISTRIBUTION: By Order of the Secretary of the Army: GERALD B. OKEEFE Secretary of the Army Mark A. Milley 1621402LTG Nadja Y. West MG Brian C. Lein

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October December 2016 12014 : A Record-Breaking Year for West Nile Virus Positive Mosquito Pools in Harris County and the City of Houston, Texas Yvonne H. Randle Martin Reyna, MS Cheryl Battle Freeman Mustapha Debboun, PhD, BCE* Monique Jackson ABSTR A CT In the 14 years since the emergence of West Nile virus (WNV) in Harris County and the city of Houston, Texas, ing this 14-year period, mosquito surveillance operational areas in Harris County were expanded from 248 to 268 and the distribution of the virus activity in mosquitoes varied from year to year. Operational areas with WNV infected mosquitoes increased from 137 in 2002 to 197 in 2006, decreased to 71 areas in 2007, and to an all-time low of 18 in 2008. The number increased to 78 areas in 2009, 96 in 2010, 133 in 2011, and 177 in 2012, sion was high in 2002 with 227 WNV positive mosquito pools. The number of positive mosquitoes remained elevated for a number of years and then declined from 2007 to 2010. Three record high years for WNV activity tivity declined in 2012, followed by a marked decline in 2013 with only 147 WNV positive mosquito pools. In West Nile virus (WNV) is a mosquito-transmitted, arthropod-borne virus maintained in nature in a birdmosquito transmission cycle. It belongs to the genus Flavivirus (family Flaviviridae) and is closely related to St Louis encephalitis (SLE) virus. Humans, horses, and other vertebrates are dead-end hosts that do not produce transmission cycle.1 Prior to 1999, WNV was geographi cally distributed in Africa, the Middle East, India, and western and central Asia, with occasional epidemics oc curring in Europe.2 During the summer of 1999, WNV was detected in New York and has since emerged in all 48 contiguous states of the United States (not in Alaska and Hawaii) and other areas of the Americas including Canada, Mexico, and the Caribbean Islands.3,4 It was in troduced into Harris County (HC), including the city of Houston, Texas, during the summer of 2002 with virus outbreaks occurring each year thereafter. The primary vector of WNV in HC is the Culex quinquefasciatus Say mosquito. The emergence of WNV into HC and the Houston met ropolitan area in 2002 brought about major changes in mosquito surveillance and testing for arboviruses at Harris County Public Health, Mosquito Control Division (MCD). Prior to that, the main focus for surveillance, testing, and control was SLE virus which then shifted and trapping were expanded from 248 to 268 operation al areas within HC and Houston (Figure 1). The enzyme-linked immunosorbent assay (ELISA) an tigen capture assay, originally developed for SLE, was adapted for WNV.6 Subsequently, the number of speci mens being tested increased dramatically. The Rapid Analyte Measurement Platform (RAMP) test (Response Biomedical Corp, Burnaby, British Columbia, Canada), a rapid and accurate WNV antigen assay, was success fully incorporated into the testing program in 2003.7Because the MCD vector control decisions were based upon mosquito surveillance and virology laboratory test data, the time between submitting mosquito samples for cant limitation. Mosquito pool samples were tested in weekly batches and the lag time from collection to ob taining test results was usually a week or longer. Chang es in the surveillance and virology laboratory testing 2006. Specimen processing, ELISA, and RAMP testing *The US Army Medical Department (AMEDD) Journal thanks Dr Debboun for his work developing this issue focused on public health. He co ordinated and managed the call for manuscripts, then the review and selection of the content, as he has done annually developing similar issues since 2006. When he retired as a Colonel from the US Army, he was Director of the Department of Preventive Health Services at the AMEDD Center and School and Chairman of the Editorial Review Board of the AMEDD Journal at Fort Sam Houston, San Antonio, Texas.

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2 http://www.cs.amedd.army.mil/amedd_journal.aspxwere then conducted 3 times per week. Consequently, the gaps between collection, testing, and reporting of results were narrowed to 3 days, which also expedited control efforts. Detailed mosquito surveillance and testing records were recorded in a Microsoft Access database maintained by the Technical Operations Branch of the MCD. At the end of each year, the data was analyzed and reported in the Annual Summary Reports of Mosquito Surveillance and MA TERI A LS A ND METHODS In pretest preparations in the virology laboratory at MCD, pooled samples of Cx quinquefasciatus mosqui toes were placed in microcentrifuge tubes with a bovine albumin buffered solution (BA-1) and one steel bead per tube. The specimens were ground in Qiagen TissueLy ser II mills (Qiagen Sciences, Inc, Germantown, MD), enates were screened by ELISA Antigen Capture As say for both SLE and WNV.6 An ELISA plate reader (BioTek EL800), in conjunction with BioTek KCJunior software (BioTek Instruments, Inc, Winooski, VT) were used to measure the degree of color development and light absorption within the individual test plate wells. The reader/software system determined the amount of antigen in each sample and calculated the mean optical density (OD) value of each set of duplicate test wells. Positive ELISA tests were determined by comparing the samples OD values to the mean OD of the negative con trols.The resulting data was exported to a Microsoft Ex cel spreadsheet to tabulate the comparative values. The WNV ELISA positive pools were further tested by the The RAMP WNV assay is an immunochromatographic test for detection of WNV in mosquitoes. A measured amount of the test samples in RAMP buffer was trans ferred to the sample well of the WNV test cartridge (TC) using a pipette and the supplied assay pipette tip. The tagged with WNV antibodies. As the sample migrated through the cartridges, WNV antigen bound particles 2014 : A RE C O RD-B R E A KIN G YE AR FO R WES T NILE VIR US POSI T I V E MOSQUI T O POOLS IN H ARR IS COU NTY AN D TH E CI TY OF HOUS T O N TEX A S Figure 1. Mosquito surveillance map showing 268 mosquito control operational areas in Harris County, which includes the city of Houston, Texas.

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October December 2016 3 tibodies and a portion of excess (control) particles were immobilized at the internal control zone.8 emitted by the particles bound at each zone and calculated a ratio between the measurements.7 The results were displayed as a numerical value (RAMP units) on the reader screen. From 2003 to 2013, mosquito pools with RAMP units greater than or equal to 2.4 were con to be acceptable after discussions with the manufacturer showed that the BA1 grinding buffer used in the MCD virology laboratory affected the reading curve of the RAMP system. In 2014, the negative cut-off value was changed after the lowest numerical value displayed for the RAMP WNV test was revised by the manufacturer to 10.0 units (from 2.4). Results below 10.0 display as 10 units or less and are considered negative. These updated of WNV ELISA positive pools. RESULTS The distribution of virus activity in mosquitoes in the 268 surveillance areas varied similarly to the number of positive mosquitoes. As shown in Figure 2, over the last itive mosquitoes varied from year to year. There were 137 infected areas in 2002 and about the same number of 71 areas in 2007 and an all-time low of 18 in 2008. The number of positive areas rose to 78 in 2009, 96 in 2010, and 133 in 2011. The number spiked to 177 in 2012, then drastically dropped to 73 areas in 2013. In 2014, an un Records in the mosquito surveillance database show that the inner Highway 610 Loop areas, Kingwood in northeast HC, and the northwest quadrant of HC pro vided hot spots of viral activity during the majority of the peak mosquito seasons. From 2009 to 2013, heavy concentrations of WNV were also found in the south east, southwest, north-central, and far west areas. Due to the widespread presence of WNV, the number of Cx quinquefasaciatus and other mosquito species ( Ae des albopictus Skuse and Ae aegypti (L.)) tested more than doubled after 2002. In 2002, 7,298 mosquito pools were tested, and more than 11,000 were tested annually beginning in 2003 (Figure 3). The numbers progres sively increased, reaching a record of approximately both 2008 and 2009. In 2010, there was a decrease in the number of mosquito pools tested (13,860), but an in crease in 2011 (14,396) due to increased viral activity. each year. Surveillance and testing continued through out the winter months but with lower numbers of mos quitoes. However, in 2014, more than 10,000 mosquito additional mosquito pools were tested in the latter 10 of the 20 weeks, culminating in a season total of 12,608. between January and the end of December, resulting in 1,269 more pools than 2014. 137 130 139 175 197 71 18 78 96 133 177 73 233 1382002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20150100 200 250 50 150 WNV Positive Surveillance AreasFigure 2Culex quinquefasciatus in Harris County, including the city of Houston, Texas, each year from 2002 to 2015.

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4 http://www.cs.amedd.army.mil/amedd_journal.aspxOver the past 14 years, the number of mosquitoes in several high count years, and a few years with very low numbers (Figure 4). The number of WNV positive mos quitoes remained elevated for a number of years and quito pools. Similarly, 2011 had a high number of virus pools. There was a decline in WNV activity (227) in 2012, followed by a marked decline in 2013 with only 147 WNV positive mosquito pools. ed in week 23 (June 6). The numbers steadily increased WNV positive mosquito pools in a single summer sea son, far surpassing those of any of the previous 12 years. In the second week of July, more than 100 positive peak of viral activity occurred in week 30 (July 20-26), with a re cord number of 168 WNV posi tive mosquito pools. The number of positive pools began declin ing in late August with a reduc week until the end of Septem ber when only 9 WNV positive mosquito pools were detected for week 40 on October 3, 2014. WNV positive mosquito pools more than 800 from 2014. In HC and Houston, mosquito surveil lance collection records and test results were recorded in a database according to weekly calendars of each year (Table 1). A detailed analysis of the virus transmis sion period, during each of the 14 years of virus outbreaks showed that a peak tive mosquitoes occurred in weeks 30 to However, in 2007, the greatest number of positive WNV mosquito pools occurred later in the year (week 42, October 14-20), as shown in Table 2. pools occurred in the second week of June (week 24, continued over a 20 week period from June to November. The highest number of positives (32) occurred in week 31 (July 28-August 3). In 2003, WNV was detected over 24 weeks from May to November. Week 30 (July 20-26) had the highest number of positive mosquitoes with 64 from June to December over a period of 27 weeks. The week period with a peak number of 137 in August. Al though there was a longer mosquito WNV detection pe riod in 2004, the number of positive samples was lower In 2006, the mosquito WNV transmission period was the longest of the years studied with a duration of 31 weeks from May 9 to December 6. The peak activity 2014 : A RE C O RD-B R E A KIN G YE AR FO R WES T NILE VIR US POSI T I V E MOSQUI T O POOLS IN H ARR IS COU NTY AN D TH E CI TY OF HOUS T O N TEX A SFigure 4. The number of mosquito pools in which mosquitoes infected with WNV were de tected in Harris County, including the city of Houston, Texas, 2002 to 2015. 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 201523 86 227 239 147 598 605 406 399 838 501 805 262 1286800 1,000 200 0 600 1,200 400 1,400 Number of WNV Positive Mosquito Pools Figure 3. Number of Culex quinquefasciatus mosquito pools tested annually for WNV in Harris County, including the city of Houston, Texas, 2002 to 2015. 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 6,000 18,000 0 12,000 8,000 2,000 14,000 10,000 4,000 16,000 Number of Mosquito Pools

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October December 2016 5 from June to November with a peak of 11 positive pools in week 42 (October 14-20). In 2008, mosquito WNV was detected over a period of 13 weeks between April and October. The peak number detected from May to October in 2009, with a high num ber of 30 positive pools in week 30 (July 26-August 1). In 2010, the virus activity period extended for 22 weeks from June to December, peaking at 40 positive pools in week 33 (August 10-16). In 2011, WNV in mosqui toes was detected over 24 weeks from May to November with a peak number of 87 positive pools during week 32 (August 7-13). The season extended from May to No virus was detected from June to November for 19 weeks with a peak of 19 positive mosquito pools in week 32 (August 4-10). tive mosquito pool was detected on June 6. Beginning in the second week of July (week 28, July 06-12), over 100 positive 7 weeks. The period of high mosquito WNV risk extended for 18 weeks with a peak total of 168 positive pools dur ing week 30 (July 20-26). The number of positive pools decreased in late August (August 26-29), with a reduction of nearly September. Detection of WNV positive June 16 (week 24), and continued until week 46 in midwas detected in week 30 (July 26August 1) and closely ed with a total of 406 WNV positive mosquito pools. mosquito WNV activity in 2013 are shown in Figure dots. Heaviest concentrations of mosquito WNV activ ity were in the northern areas with scatterings in the far west, southwest, and southeast quadrants of HC. Areas inside the I-610 Loop were not as involved as in past years, and only 73 of the 268 areas county-wide were In the viral activity map of 2014 (Figure 6), nearly the lance/operational areas. A map of mosquito-borne disease activity WNV in mosquitoes was detected erational areas. The highest pro portion of WNV positive mosqui in the southwest sectors within the I-610 loop. Other highly infected areas were located in the south west and far west sections of HC. A cluster of the virus was also detected in 10 areas in Baytown, located in the easternmost sector of Harris County. Table 1. Week numbering assignments for collection/test results database pur poses relative to calendar months of 2002 to 2015.Weeks assigned to calendar months for: 2002, 2003, 2007, 2008, 2013, 2014 Weeks assigned to calendar months for: 2004, 2005, 2006, 2009, 2010, 2011, 2012, 2015 Month Weeks Month Weeks Month Weeks Month Weeks January01-05July27-31January01-04July26-30February06-09August32-35February05-08August31-34March10-13September36-39March09-12September35-39April14-18October40-44April13-17October40-43May19-22November45-48May18-21November44-47June23-26December49-52June22-25December48-52 Table 2. Mosquito WNV detection period and weeks with the highest number of positive mosquito pools from 2002 to 2015 Variable 2002 2003 2004 2005 2006 2007 2008 Virus Detection Period Jun-Nov20 weeks May-Nov24 weeks Jun-Dec27 weeks May-Oct22 weeks May-Dec31 weeks JunNov18 weeks Apr-Oct13 weeks Week No/Peak No. Positives31/32 30/64 30/65 32/137 31/97 42/11 22/6Total No. WNV Confirmed227 399 598 698 838 86 23Variable 2009 2010 2011 2012 2013 2014 2015 Virus Detection Period May-Oct19 weeks Jun-Dec22 weeks May-Nov24 weeks May-Nov25 weeks Jun-Nov19 weeks Jun-Oct18 weeks Jun-Nov25 weeks Week No/Peak No. Positives30/30 33/40 32/87 32/72 32/19 30/168 30/58Total No. WNV Confirmed239 262 605 501 147 1,286 406

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx SU MMA RY Based on the data collected since WNVs emergence into HC and Houston, mosquito WNV cases typically began in May or June, and declined to low levels in Oc tober or November. However, in 2004, 2010, and 2006, the WNV season extended into December. In 2008, it began early in April, and extended until October for a period of only 13 weeks. Six mosquito WNV outbreaks and three in December (2004, 2006, 2010). The length of the mosquito WNV detection period had no indication of the amount of WNV detected and had no bearing on the number of positive mosquito pools was detected for 18 weeks, matching 2007 which had only 86 positive mosquito pools. The shortest detection period was in 2013, lasting only 13 weeks with 23 WNV positive mosquito pools. The longest period was in 2006 which extended for 31 weeks, resulting in 838 positive pools. Each of the 14 years had a peak of WNV activ ity during late July and August (weeks 30-33), with the exception of 2007 and 2008 which had the most in week 42 (October) and week 22 (May), respectively. The distribution pattern of viral activity within the sur veillance areas of HC in any given year was equally un predictable because it differed from year to year. Areas prominently, providing hot spots of viral activity during 2014 : A RE C O RD-B R E A KIN G YE AR FO R WES T NILE VIR US POSI T I V E MOSQUI T O POOLS IN H ARR IS COU NTY AN D TH E CI TY OF HOUS T O N TEX A SFigure 5. Map of Harris County, Texas, showing 72 areas (27%147) in 2013. Positive areas are highlighted with red stripes and dots.

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October December 2016 7 10 of the 14 years (2002-2006, 2008, 2009, 2011, and 2014). Four years (2007, 2010, 2012, and 2013) had mini mal WNV activity within the I-610 loop but more in the southwest, far west, northwest, and northeast sec quito pools over multiple weeks in areas within the I-610 Loop, as well as northwest and northeast HC that gener ated multiple numbers per site. samples per area, a season that lasted 31 weeks. In 2014, WNV was much more widespread than in any other of of the 268 areas and 1,286 mosquito pools were con the season. Each of the remaining areas had fewer than REFERENCES 1. Hayes CG. West Nile Fever. In: Monath TP, ed. The Arboviruses: Epidemiology and Ecology Vol. 2. Nash D, Mostashari F, Fine A, et al. The outbreak of West Nile infection in the New York City area in 1999 N Engl J Med 2001;344:1807-1814. 3. Roehrig JT, Layton M, Smith P, Campbell GL, Nasci R, Lanciotti RS. The emergence of West Nile virus in North America: ecology, epidemiol ogy, and surveillance. Curr Top Microbiol Immu nol 2002;267:223-240. 4. Murray KO, Mertens E, Despres P. West Nile virus and its emergence in the United States of America. Vet Res 2010;41(6):67. Lillibridge KM, Parsons R, Randle Y, et al. The 2002 introduction of West Nile virus into Har ris County, Texas, an area historically endemic for St. Louis encephalitis. Am J Trop Med Hyg 2004;70:676-681.Figure 6. Map of Harris County, Texas, showing 235 areas (87.7%1,286) in 2014. Positive areas are highlighted with red stripes and dots.

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8 http://www.cs.amedd.army.mil/amedd_journal.aspx6. Tsai, TF, Bolin RA, Montoya M, et al. Detection of St. Louis encephalitis virus antigen in mosquitoes by capture enzyme immunoassay. J Clin Microbiol 7. Burkhalter KL, Lindsay R, Anderson R, Dibernar do A, Fong W, Nasci RS. Evaluation of Commer cial Assays for Detecting West Nile Virus Antigen J Am Mosq Contr Assoc 2006;22:64-69. 8. Kesavaraju B, Farajollahi A, Lampman RL, et al. Evaluation of a rapid analyte measurement plat form for West Nile virus detection based on United States mosquito control programs. Am J Trop Med Hyg 9. Burkhalter KL, Horiuchi K, Biggerstaff BJ, Savage HM, Nasci RS. Evaluation of a rapid analyte mea surement platform and real time reverse transcrip tase polymerase chain reaction assay West Nile vi rus detection system in mosquito pools J Am Mosq Contr Assoc 2014;30(1):21-30. 10. Tesh RB, Parsons, R, Siirin M, et al. Year-round West Nile Virus Activity, Gulf Coast Region, Texas and Louisiana. Emerg Infect Dis 2004;10(9):1649pmc/articles/PMC3320313/. AUTHORS Ms Randle is a retired former virologist with the Mos quito Control Division, Harris County Public Health, Houston, Texas. Ms Freeman is a Virolgist with the Mosquito Control Division, Harris County Public Health, Houston, Texas. Ms Jackson is a Virological Specialist I with the Mos quito Control Division, Harris County Public Health, Houston, Texas. Mr Reyna is the Technical Operations Manager of the Mosquito Control Division, Harris County Public Health, Houston, Texas. Dr Debboun is the Director of the Mosquito Control Di vision, Harris County Public Health, Houston, Texas.2014: A RE C O RD-B R E A KIN G YE AR FO R WES T NILE VIR US POSI T I V E MOSQUI T O POOLS IN H ARR IS COU NTY AN D TH E CI TY OF HOUS T O N TEX A SFigure 7. Map of Harris County, Texas, showing 138 areas (51.5%406) in 2015. Positive areas are highlighted with red stripes and dots. !H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H !H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H!H !H!H!H!H!H !H[ [ [ [ [ [ [ [ [ [ [ [ [ [ M O N T G O M E R Y L I B E R T Y W A L L E R F O R T B E N D G A L V E S T O N B R A Z O R I A1 1 0 1 1 0 2 1 0 3 1 0 4 1 0 5 1 0 6 1 0 7 1 0 8 1 0 9 1 1 1 1 0 1 1 1 1 1 2 1 1 3 1 1 4 1 1 5 1 1 6 1 1 7 1 1 8 1 1 9 1 2 2 0 1 2 0 2 2 0 3 2 0 4 2 0 5 2 0 6 2 0 7 2 0 8 2 0 9 2 1 0 2 1 1 2 1 2 2 1 3 2 1 4 2 1 5 2 1 6 2 1 7 2 1 8 2 1 9 2 2 2 2 0 2 2 1 2 2 2 2 2 3 2 2 4 2 2 6 2 2 7 2 3 3 2 1 3 2 9 6 0 1 6 0 2 6 0 3 6 0 4 6 0 5 6 0 6 6 0 7 6 0 8 6 0 9 6 1 6 1 0 6 1 2 6 1 3 6 2 6 3 6 5 6 6 6 7 7 0 1 7 0 2 7 0 3 7 0 4 7 0 5 7 0 6 7 0 7 7 0 8 7 0 9 7 1 7 1 0 7 1 1 7 1 2 7 1 3 7 1 4 7 1 5 7 1 6 7 1 7 7 1 8 7 1 9 7 2 7 2 1 7 2 2 7 2 3 7 3 7 4 7 5 7 6 8 0 1 8 0 2 8 0 3 8 0 4 8 0 5 8 0 6 8 0 7 8 0 8 8 0 9 8 1 0 8 1 1 8 1 2 8 1 3 8 1 4 8 1 5 8 1 6 8 1 8 8 1 9 8 2 0 8 2 1 8 2 2 9 0 1 9 0 2 9 0 3 9 0 4 9 0 5 9 0 6 9 0 7 9 0 8 9 0 9 9 1 9 1 0 9 1 1 9 1 2 9 1 3 9 1 4 9 1 5 9 1 6 9 1 7 9 1 8 9 1 9 9 2 9 2 0 9 2 1 9 2 2 9 2 3 9 2 4 9 2 5 9 2 7 9 2 8 9 2 9 9 3 9 3 0 9 3 1 9 3 3 9 3 4 2 1 3 1 3 2 3 3 3 5 4 0 1 4 1 4 1 6 4 2 4 2 1 4 3 4 4 4 5 4 6 5 0 1 5 0 2 5 0 3 5 0 4 5 0 5 5 0 6 5 0 7 5 0 8 5 0 9 5 1 5 1 0 5 1 1 5 1 2 5 1 3 5 1 4 5 1 5 5 1 6 5 1 7 5 1 8 5 1 9 5 2 5 2 0 5 2 1 5 3 5 4 5 5 6 1 4 3 0 2 3 0 3 3 0 4 3 0 5 3 0 6 3 0 7 3 0 9 3 1 0 3 1 2 3 1 3 3 1 4 3 1 5 3 1 6 3 1 7 3 1 8 3 1 9 3 2 0 3 2 2 3 2 3 3 2 4 3 2 5 3 2 6 3 2 7 3 2 8 3 3 1 3 3 2 3 3 3 3 3 4 4 0 2 4 0 3 4 0 4 4 0 5 4 0 6 4 0 7 4 0 8 4 0 9 4 1 0 4 1 1 4 1 2 4 1 3 4 1 4 4 1 5 4 1 7 4 1 8 4 1 9 4 2 0 4 2 2 4 2 3 4 2 4 4 2 5 4 2 6 4 2 7 4 2 8 9 3 8 9 3 7 9 4 0 9 3 6 9 3 5 9 3 2 9 2 6 7 2 0 2 2 5 6 4 8 2 3 9 3 9 3 3 0 8 1 7 3 4 6 1 1 3 1 1 3 0 8 8 1 3 0 1 So u rc e s : Es ri H ER E, D e L o rm e T o m T o m I n t e rm a p i n c re m e n t P C o rp G EBC O U SG S, F AO N P S, N R C AN G e o Ba s e I G N Ka d a s t e r N L O rd n a n c e Su rv e y Es ri J a p a n M E T I Es r i C h i n a (H o n g Ko n g ), s w i s s t o p o M a p m y I n d i a O p e n St re e t M a p c o n t ri b u t o rs a n d t h e G I S U s e r C o m m u n i t y C. 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October December 2016 9Richmond County is located on the Georgia/South Car olina border, about 150 miles (240 km) east of Atlanta and 70 miles (110 km) west of Columbia. According to the US Census Bureau (2015), the county has a total area of 329 square miles; 324 square miles is land and 4.3 square miles (1.3%) is water. Richmond County is in the Savannah River basin.1Augusta is the principal city of the Augusta-Richmond County Metropolitan Statistical Area, which as of 2012 had an estimated population of 580,270,1 making it the third-largest city and the second-largest metro area in the state after Atlanta. Augusta is located about halfway up the Savannah River on the fall line, which creates a number of small falls on the river. The city marks the end of a navigable waterway for the river and the entry to the Georgia Piedmont area. The Richmond County Mosquito Control program is a part of the Richmond County Environmental Health of al workers that was established in 1983 in response to the emergence of a large nuisance mosquito problem. Some limited surveillance was done in the county in response to West Nile virus (WNV), but the program worked to create partnerships with other county and local agencies, as well as with the Georgia Department of Public Health (GDPH), with the intent to expand the program into a fully functioning, integrated pest management operation. Some surveillance was done by the state entomologist in response to either complaints or WNV cases beginning seasonal mosquito surveillance technician for the year. mosquito surveillance, in 2014 the Richmond County Mosquito Control program joined forces with the Phin quality research organization in order to trap mosquitoes at sites across the county and identify them to species. These data helped determine locations of disease-carry ing mosquitoes during the 2015 WNV season, allowing mosquito control to prioritize their control efforts, reduc ing the risk of viral transmission in Richmond County.2 The GDPH supported these efforts with free mosquito Phinizy Swamp, as well as providing use of the GDPH emergency mosquito surveillance trailer with its comple ment of mosquito surveillance equipment.3A Multiagency Approach to Reducing West Nile Virus Risk in Richmond County, Georgia, in 2015 Rosmarie Kelly, PhD, MPH Fred Koehle R. Chris Rustin, DrPH, MS, REHS ABSTR A CT The Richmond County Mosquito Control programs mission statement is to incorporate strategies of integrated mosquito control management that are effective, practical, and environmentally safe and protect the health of Rich mond County residents, as well as promote public education, in order to prevent large mosquito populations and the diseases that they transmit. To this end, the program coordinates efforts with other county agencies in order to provide better service. This is a small program with limited resources, so in an effort to provide better integrated mosquito management, the mosquito control program and the Phinizy Center for Water Sciences joined efforts to trap mosquitoes at sites across the county, identify the species, and send the mosquitoes off for viral testing. These quito populations and reduce the risk of West Nile virus transmission. The Phinizy Center for Water SciencesThe Phinizy Center for Water Sciences was established to provide leadership to balance sustainable watersheds and economic vitality through solutions-based research, education, and public involvement (http://phinizycenter. org). The Phinizy Center manages the Phinizy Swamp Nature Park, a 1,100-acre nature park in the city of Augusta. The park contains wetlands and woodlands and has a campus for water research and environmental education. As the wetlands at Phinizy Swamp Nature Park obviously have the potential to contribute to mosquito problems in Richmond County, the scientists at the Phinizy Center are intimately involved in efforts to address the risks.

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10 http://www.cs.amedd.army.mil/amedd_journal.aspxWest Nile virus is a mosquito-borne viral pathogen that was introduced into the United States in 1999. Within 4 years following its initial detection in New York, WNV was detected in states from the East and West coasts as well as in Mexico and Canada.4 infects humans who are bitten by mosquitoes that have been feeding on birds. Most people (approximately 80%) infected with WNV do not develop symptoms. illness, often termed West Nile fever, characterized by fever, headache, muscle weakness or myalgia, ar thralgia, and sometimes rash. Less than one percent of persons infected with WNV develop neurologic illness (West Nile neuro logic disease (WNND)) in the form of meningitis, encephalitis, or possibly proximately 3% to 15% of WNND cases are fatal. Risk of WNND is associat ed with increasing age and the presence of underlying medical conditions. The presence of WNV in an American crow from Lowndes County tested posi tive for the virus. Since then, human cases, equine cases, positive birds, and positive mosquito pools have been detected every year within the state. Since 2012, human cases have been reported every year in Richmond County (Table 1). Since mosquito control is a small program, it was determined that an inter agency approach was needed to better target mosquito control to reduce mosquito populations and reduce the as areas with a human WNV case or a WNV positive mosquito pool. METHODS 5-step action plan for responding to a potential WNV outbreak:Step 1: risk area without identifying case location (Figures 1 and 2). For human cases, the street name is obtained from the GDPH District Epidemiologist. (Note: The state of Georgia is divided into 18 public health dis tricts of varying size based on population.)Step 2: provided by the Center for Water Science at Phini zy Swamp. When a WNV positive case is detected, trapping equipment will be positioned to establish 2 locations on each side of the positive site. Traps will be set every 2 weeks, and selected species will be continue until the end of the year.Step 3: Realign the spray areas to include WNV posi tive locations. Use a thermal fogger in overgrown test positive for WNV, reevaluate the spray areas and patterns. Add an additional spray event in the early morning to control daytime biters (Table 2).Step 4: Conduct a neighborhood survey (Figure 3) to locate any other mosquito habitats that can be elimi nated or treated, working with code enforcement, an department to write citations if necessary. Once com pleted, reevaluate the spray areas with any new infor mation and make any necessary adjustments.Step5: Continue the public awareness program. This includes media events, health fairs, and a family emergency planning day. The non-WNV positive areas continued to be sprayed as needed and were monitored for other complaints. Sur veillance in these areas is done every 2 weeks. A MULTI AG E NC Y APP R O AC H TO REDU C ING WEST NILE VIR US RISK IN RI C H M O N D COU N TY, GEO RG I A IN 2015 Table 1. Human Cases of WNV: Georgia statewide and Richmond County, 20012015*Year Georgia S tatewide Richmond County 2001 6 2002 36 2003 55 2004 23 2 2005 24 1 2006 11 2007 55 3 2008 12 2009 6 2010 14 2011 25 2012 117 4 2013 20 1 2014 13 2 2015 15 3*Data from GDPH Arboviral Surveil lance and Richmond County Mos quito Control records. Table 2. Spray and Trapping ScheduleD ate Procedure8/25/2015First morning spray (7:45 to 8:45)8/27/2015Evening spray (6:30 to 7:30)8/31/2015Baseline trapping at 4 selected sites9/1/2015Morning spray9/3/2015Evening spray9/4/2015Mosquito pools from baseline sent for testing*9/8/2015Morning spray9/10/2015Evening spray9/15/2015Morning spray9/15/2015First trapping of regular series (every 2 weeks)9/17/2015Evening spray9/17/2015Mosquito pools from regular series sent for testing*9/22/2015Morning spraying cancelled due to rain9/24/2015Evening spray*Virus testing conducted by University of Georgia College of Veterinary Medicine as part of the Southeastern Cooperative Wildlife Disease Study (http://vet.uga.edu/scwds).

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October December 2016 11 RESULTS Typically, Richmond County has very few WNV husince 2012, there have been cases reported every year in Richmond County. Mosquito surveillance had been a missing component of the Richmond County Mosquito Control Program. The creation of a part nership with the Phinizy Center for Water Sciences has resulted in better focused mos case in Richmond County was reported in ter. A third case was reported the following month. All 3 cases were less than 10 miles from one another. Culex quinquefasciatus proximately a half mile in search of a blood in the area between and around the 3 case sites, Richmond County Mosquito Control implemented their 5-step response program. The 2015 area surveillance in the high risk area (Figure 2) collected 12 different mos quito species, including Culex quinquefas ciatus sampled from one pool tested positive for WNV (Table 4). Although the number of WNV cases in Richmond County has his torically not been high, the ability to better target mosquito control has helped reduce risk of disease transmission. CONCLUSIONS Although complaints by residents can pro vide some information on the presence of mosquito problems in a given area, surveil lance allows the targeting of areas where vector populations are high. Surveillance and viral testing also provides a means of determining the effectiveness of control ef forts. Although some level of surveillance was done in Richmond County almost ev ery year starting in 2004, it was primar ily performed once a month. More frequent surveillance is needed to support targeted mosquito control efforts. The collaboration with the Phinizy Center has changed mosquito control operations tifying areas of the county with diseasecarrying species helps to accomplish the primary mission of aiding public health by reducing the number of vector species and reducing the risk of dis ease transmission. The current goal is to increase public education pro grams with civic clubs, churches, schools, homeowners associations, and public events. Outreach to the public Figure 1. Map of Richmond County, Georgia, showing the high risk area of concern. Figure 2

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12 http://www.cs.amedd.army.mil/amedd_journal.aspxA MULTI AG E NC Y APP R O AC H TO REDU C ING WEST NILE VIR US RISK IN RI C H M O N D COU N TY, GEO RG I A IN 2015Date and time: October 20, 2015 10 AM to 3 PM People involved: 5 from Mosquito Control 1 from Environmental Health as observer 1 from Center for Water Sciences (trapping and identification) 5 from Augusta/Richmond County Code Enforcement 3 from Richmond County Marshals department 6 from Richmond County Sheriffs department Animal control was on standby due to personnel shortage. 142 Properties surveyed (Figures 1, 2): 32 houses on Bandler Rd 49 houses on Circular Dr 15 houses on Harold Dr 17 houses on Sanders Rd 26 houses on Martin Rd 3 houses on Ivey Rd Age of houses in survey area: 80% of the houses in the survey area were built between 1944 and 1952. All houses are located within a 180-acre area divided equally on both sides of a major 4 lane highway. All houses on both sides are similar in age and maintenance. Construction materials range from brick to lap board and T-11. Most carports are aluminum. Almost all houses have crawl spaces which are well known as mosquito habitats. Figure 3. Neighborhood survey following surveillance and treatment of area of concern. Table 3. Mosquito Surveillance Data From a High Risk AreaS pecies08/31/15 09/02/15 09/09/15 09/23/15 10/14/15S pecies T otal Aedes albopictus115 113 88 98 65 479Aedes vexans 1 16 2 19Anopheles crucians complex 4 4Anopheles quadrimaculatus 2 2 13 4 21Culex erraticus 27 2 29Culex nigripalpus 1 2 3Culex quinquefasciatus6 19 2 147 38 212Culex salinarius 69 30 3 779 881Ochlerotatus triseriatus1 4 3 8 16Orthopodomyia signifera 2 2Psorophora columbiae 1 2 2 5Psorophora ferox 1 1Grand Total122 236 139 275 900 1,672 Table 4. Richmond County Mosqui to Surveillance Results, 2004-2015 Year WNV T est Results Y early T otalNegative Positive 2004 17 17 2006 373 373 2007 1,395 7 1,402 2008 1,906 1,906 2009 841 841 2010 212 212 2011 384 384 2012 4,992 4,992 2013 2,272 2,272 2014 111 111 2015 747 25 772Grand Total13,250 32 13,282

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October December 2016 13 is the best method of reducing mosquito habitats for the better health of the citizens of Richmond County, es sented by the Zika virus. REFERENCES 1. US Census Bureau. Quick Facts; Richmond Coun ty, Georgia. US Census Bureau website. Avail able at: https://www.census.gov/quickfacts/table/ PST045215/00,13245. Accessed May 31, 2016. 2. Mirshak M. Phinizy Center, Richmond County Mosquito Control join efforts to identify mosquito species [internet]. The Augusta Chronicle August 9, 2015. Available at: http://chronicle.augusta.com/ news/metro/2015-08-09/phinizy-center-richmondcounty-mosquito-control-join-efforts-identifymosquito#. Accessed May 31, 2016. 3. Georgia Mosquito Control Association. Georgia Emergency Surveillance Trailer Protocols. Georgia Mosquito Control Association Website. Available at: http://www.gamosquito.org/resources/Georgia EmergencyMosquitoSurveillanceTrailerUseProto cols.pdf. Accessed May 31, 2016. 4. Centers for Disease Control and Prevention. West Nile virus [internet]. CDC website. Available at: http://www.cdc.gov/westnile/. Accessed May 31, 2016. AUTHORS Dr Kelly is a Public Health Entomologist with the VectorBorne & Zoonotic Diseases Team Environmental Health Section, Georgia Department of Public Health, Atlanta, Georgia. Mr Koehle is with the Environmental Health Section of the Richmond County Department of Public Health, Au gusta, Georgia. entist, Phinizy Center for Water Sciences, Augusta, Georgia. lic Health, Georgia Southern University, Statesboro, Georgia. 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 relevant information using any of several bibliographic search tools, including the NLMs PubMed service.

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14 http://www.cs.amedd.army.mil/amedd_journal.aspxThe role of the Royal Australian Army Medical Corps and the US Army Medical Department is to provide the best medical care for members of the Australian and US armed forces. The task to provide protection against vector-borne diseases such as malaria, dengue, arbo viruses, and others is undertaken by various groups in both countries. In Australia, this work has been under at the Army Malaria Research Unit (AMRU), which be came the Army Malaria Institute (AMI),1-6 and in the United States, the Walter Reed Army Institute of Re search (WRAIR) in Forest Glen, MD, and its overseas laboratories.7Collaboration between the United States and Australia work conducted between 1941 and 1945 by the Austra lian Land Headquarters Medical Research Unit is de scribed in detail by LTC A. W. Sweeney in his book, Malaria Frontline .8During the Vietnam War, many cases of vector-borne disease were observed in Australian, United States, and other Allied defense personnel. The medical resources and personnel of both countries collaborated to optimize and evaluate measures against diseases. The high num ber of malaria cases in Australian soldiers in Vietnam in 1965 resulted in the establishment in 1966 of the 1 Malaria Research Unit, under the direction of Professor Robert H. Black at the University of Sydney. This unit was moved to Ingleburn, 35 km southwest of Sydney, New South Wales, in 1974.1In 1985, LTC Sweeney visited medical research units in the United States and fostered a formal collaboration be pellents and permethrin treated military uniforms at Cow was conducted by 4 scientists from the Letterman Army Institute of Research, Presidio of San Francisco, and AMRU. The study showed that a combination of wearing permethrin treated battle dress uniforms and repellents containing deet provided the best protection against mos quitoes.9 conducted by AMRU and the US Department of Agri culture compared methods of protection against trombiculid larvae (chiggers). This study showed that permethrin treated uniforms provided protection against mites that cause scrub itch.Protection of Military Personnel Against Vector-Borne Diseases: A Review of Collaborative Work of the Australian and US Military Over the Last 30 Years Stephen P. Frances, PhD Mustapha Debboun, PhD, BCE Michael D. Edstein, PhD G. Dennis Shanks, MD ABSTR A CT Australian and US military medical services have collaborated since World War II to minimize vector-borne LT Doug Waterhouse, Royal Australian Army Medical Corps, conducting mosquito repellent tests at Lalipipi village in Papua New Guinea during World War II (1943). Mention of a commercial product does not constitute an endorsement of the product by the Australian Defence Force or US Department of Defense.

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October December 2016 15 EXCH A NGE SCIENTISTS Medical Officers in Malaysia at the US section of the Institute of Medical Research on protection against scrub typhus and snake envenom ation. The joint studies conducted showed that doxycy cline was an effective prophylaxis for scrub typhus,11 was underreported.12,13Exchange Scientists in Thailand and AustraliaIn 1988, the US section of IMR Malaysia closed and an exchange was established with the Armed Forces Re search Institute for Medical Sciences (AFRIMS) in Bang kok, Thailand, and the Australian AMRU. Between 1989 and 1992, MAJ M. D. Edstein from AMRU worked at AFRIMS primarily on preclinical drug development and clinical evaluation of standard and new antimalarial drugs. During this 3-year period, MAJ Edstein and US Army and Thai Army collaborators researched new antimalar ial compounds using nonhuman primates for causal pro phylactic and radical curative activity. Of these studies, WR182393, a non-8-aminoquinoline guanylhydrazone, exhibited both causal prophylactic and radical cura tive properties in the rhesus monkey ( Macaca mulatta )/ Plasmodium cynomolgi test model, a vivax malaria-like model.14 However, using the same model, the prophylac tic combination of proguanil plus sulfamethoxazole was found not to be causally prophylactic.15 Additionally, the shown to extend the prepatent period of P cynomolgi from 8.5 days to 18.3 days in drug-treated monkeys, but did not prevent a primary infection.16For clinical studies, new high performance liquid chro matographic (HPLC) methods were developed for the analysis of antimalarial drugs such as quinine,17 halo fantrine,1819 and These HPLC methods were used to char acterize the pharmacokinetic-pharmacodynamic interac P falciparum malaria on the Thai-Burma/Myanmar* border,21 quine chemoprophylaxis,22 evaluate the potential of cip 23 assess the effect of food on the disposition of halofantrine in treating falciparum malaria24 and determine the effec resistant falciparum malaria.25 ment of choice for uncomplicated multiresistant falci quine became ineffective in treating acute falciparum malaria in an area with deteriorating multidrug resis tance on the Thai-Myanmar border. By increasing the 26 Adverse events were dose-related and included dizzi ness, anorexia, nausea, vomiting, and fatigue. respectively, also became ineffective. In 1985-1986, MSP laria on the Thai-Myanmar border. Four years later, the that P falciparum had rapidly developed resistance to pyrimethamine. The recommendation was to abandon the MSP combination.21 The development of resistance new antimalarial drugs such as halofantrine. The recom MAJ Michael Edstein of the AFRIMS Department of Immunology (on assignment from the Australian Army Malaria Institute), and MAJ Catherine (Dahlem) Smith, US Army, Chief of the Department of Veterinary Medicine, team up to administer an antimalarial drug to a monkey in a pharmacokinetic study (1990). Photo courtesy of AFRIMS photograph archives. *The country of Burma was renamed Myanmar in 1989.

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx given with food to enhance drug absorption. However, this halofantrine regimen was found soldiers who showed slide-positive results for phylaxis.22 The serum halofantrine concentra tions were higher in patients cured by halofan trine compared with those who failed treatment. These observations suggested that the 24 mg/ kg regimen of halofantrine was not optimal for the treatment of multiple drug-resistant falci parum malaria in Thailand. A higher dose of halofantrine (72 mg/kg) was more effective in treating uncomplicated falciparum malaria with cardiotoxicity was observed and required inves tigation.26 Studies by other investigators led to the demise of halofantrine due to cardiotoxicity. In 1992, MAJ Edstein was replaced at AF RIMS by MAJ S. P. Frances, an entomologist, who worked on personal protection measures against malaria vectors, and biology of the vec tors of scrub typhus. While at AFRIMS, Fran of repellents and toxicants against mosquito vectors of malaria and mite vectors of Orien tia tsutsugamushi .27-33 He also worked on vec tors of scrub typhus, resulting in the establish ment of colonies of Leptotrombidiun deliense (mites) naturally infected with O tsutsugamu shi and improved understanding of the ecology of mites, rodent hosts, and the pathogen that causes scrub typhus in Thailand.34-44During the same time (1992-1995), LTC G. D. Shanks worked at AMRU in Australia. He worked closely with MAJ Edstein, who had returned to Australia, on development of anti during this time included several clinical trials in Papua New Guinea.45-48 COLL A BOR A TIVE PROJECTS Collaboration between AMI and US military scientists personal protection measures against mosquitoes was US repellents was conducted in Australia at Cowley Beach by the AMI with US Army MAJ M. Debboun from WRAIR. The study compared the protection pro vided by commercial and military repellent on human volunteers.49 This collaboration continued with evaluation of additional active ingredients in the laboratory bednet in Papua New Guinea.51 The prototype bednet that was tested has been in use by US military person nel for more than a decade.52 More recently, 3 books on repellents and personal protection measures used by ci vilian and military personnel were edited by US Army and Australian Defence Forces entomologists.53-55 MAJ Stephen Frances (ADF) treating Royal Thai Army uniforms with permethrin from a back pack aspirator in Sisaket Province, Thailand, 1992. MAJ Stephen Frances (AMI), Dr Nigel Beebe (University of Technology Sydney, Australia), MAJ Mustapha Debboun (WRAIR) and Senior COL Nguyen van Dung (Vietnam Peoples Army), at Cowley Beach Training Area, northern Queensland, Australia, during mosquito repellent trials in 2001. *deet (diethylmethyl benzamide); AI3-37220 (1-(3-cyclohexen-1-cabonyl)-2-methylpiperidine); CIC-4 (2-hydroxomethylcyclohexl) acetic acid)P RO TE C TI O N O F MIL IT ARY PE RSO NNE L AG A IN S T VE C T OR -BOR NE DI S E AS E S : A RE V IE W O F C OLLABORA TI V E W OR K O F THE A US T RAL I A N A N D US MIL IT ARY O V E R THE L AS T 30 YE ARS

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October December 2016 17 ers Program of the Armed Forces Pest Manage of Australian military shirt fabrics treated with permethrin to be tested to determine protection against mosquito bites of malaria and dengue vectors.56,57Drug Development malarial drug was reviewed by Shanks.58 The constraints of shrinking military and civilian budgets for development of antimalarial drugs highlighted the need to continue to conduct collaborative development of drugs. Despite this, collaborative research to develop new an timalarial drugs between the two nations has continued. undertook collaborative evaluation of the new antima or etaquine) for malaria prevention and in vitro stud ies into artemisinin induced dormant ring-stages of P falciparum as a plausible explanation for recrudescence. Ubon Ratchatani province, Thailand, with Thai soldiers and collaborators from Australia, United States, and Thai military.59 The major focus of the study was to de kinetics of tafenoquine following an oral loading dose 59 In participants completing the follow-up period (96 tafenoquine and 91 placebo recipients), there were 22 P vivax 8 P falci parum and one mixed infection. With the exception of one P vivax infection in the tafenoquine group, all infec tions occurred in placebo recipients, giving tafenoquine P vivax P falciparum malaria. The soldier in the tafenoquine group who developed malaria during the study had a lower plasma tafenoquine con was approximately 3-fold lower than the trough concen trations of the other soldiers who were protected from infection by tafenoquine. The phase II study revealed that monthly tafenoquine was safe, well tolerated, and highly effective in preventing P vivax and multidrugresistant P falciparum malaria in Thai soldiers during 6 gation of tafenoquine in Southeast Asia and in protecting volunteers from both P vivax and P falciparum malaria. To assist in the development and evaluation of tafeno quine, a rapid and sensitive HPLC method for tafeno quine was developed by CPT D. A. Koscisko, US With this method, the population pharmacokinetics of tafenoquine was characterized in Thai soldiers who par ticipated in the phase II study.61,62 A one-compartment model was found best to describe the pharmacokinetics of tafenoquine after oral administration. The drug is widely distributed to body tissues with a high appar ent volume of distribution and a lengthy elimination half-life of 16.4 days, suitable for weekly prophylaxis. LTC D. E. Kyle, US Army, established the WRAIR of the drug Artimisone, which showed it was more effective than artemisinin drugs in curing P falci parum in Aotus monkeys.6,63,64 He has continued col laboration with AMI in his role as a professor at South Florida University with studies of the role of gene am P falciparum .65-68 LTC Pamornwan Singsawat, Royal Thai Army, and LTC Douglas Walsh (AFRIMS) interview potential subjects in a joint malaria prophylaxis drug study among Thai soldiers in Ubon Ratchathani (1998). Photo courtesy of AFRIMS photograph archives. New Guinea, in 1999.

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18 http://www.cs.amedd.army.mil/amedd_journal.aspx States and was replaced at AMI by MAJ Mike ONeil. of the pharmacodynamics and pharmacokinetics of the monkeys using an in vivo-in vitro (ex vivo) model.69 In a 2-phase crossover design, cynomolgus monkeys were monkeys were assessed for ex vivo antimalarial activ ity against P falciparum lines having wild-type (D6), C2A) DHFR-thymidylate synthase (TS) and a P falci parum line transformed with a P vivax dhfr-ts quadru spectrometry. The mean inhibitory dilution (ID) of monkey plasma at 3 hours after the last dose against D6, tively. Less activity was observed with the same mon key plasma samples against the D6-PvDHFR line, with a mean ID of 53. Geometric mean plasma concentra after both regimens (6.6 versus 11.1 hours). The high ex P falciparum DHFRTS quadruple-mutant lines provides optimism for the WRAIR laboratory at AMI. He participated in a major Initiative assisting in malaria eradication efforts in the Solomon Islands and Vanuatu. The Drug Resistance and Diagnostics department of AMI collaborated with LTC Waters on studies of the molecular assessment of parasite drug resistance.71 They found that P falciparum from both Solomon Islands and Vanuatu had high levels of resis tance to Chloroquine72 and Fansidar.73 LTC Waters was next assigned to the US Military Academy, West Point, THE FUTURE working in Australia at AMI, the exchange program ever, the collaboration between the 2 countries contin drug development, and pharmacology. With the contin and different priorities within the US and Australian Defence Forces, continued collaboration is important to continue to conduct valuable research on a variety of vector-borne diseases. The effect of malaria, dengue, and scrub typhus have remained focal for both coun tries, and collaborative research will continue to mini mize the impact of these diseases on military personnel and civilians alike. ACKNOWLEDG M ENTS We thank Mrs Oranuch, AFRIMS, Bangkok, Thailand, for allowing us to use archival photos from AFRIMS collec tion. Studies reviewed in this paper were supported by a number of funding agencies, and we thank them for their support of both the Australian Defence Force and the US Department of Defense. The opinions expressed herein Joint Health Command (Australia) or any Defence policy. REFERENCES 1. Rieckmann KH, Sweeney AW. Army Malaria Institute-its evolution and achievements. First de cade: 1965-1975. J Mil Vet Hlth. 2. Rieckmann KH, Edstein MD, Cooper RD, Swee ney AW. Army Malaria Institute-its evolution and achievements. Second decade: 1975-1985. J Mil Vet Hlth 3. Rieckmann KH, Sweeney AW, Edstein MD, et al. Army Malaria Institute-its evolution and achieve J Mil Vet Hlth 4. Rieckmann KH, Frances SP, Kotecka BM, et al. Army Malaria Institute-its evolution and achieve J Mil Vet Hlth 5. Rieckmann KH, Q Cheng, R Cooper, et al. Army Malaria Institute-its evolution and achievements. J Mil Vet Hlth 6. Rieckmann, KH, Q Cheng, SP Frances, et al. Army Malaria Institute-its evolution and achievements. J Mil Vet Hlth 7. Gambel JM, RG Hibbs. U.S. military over seas medical research laboratories. Mil Med 8. Sweeney AW Malaria Frontline, Australian Army Research during World War II Melbourne, Victo 9. Gupta RK, Sweeney AW, Rutledge LC, et al. Ef fectiveness of controlled-release personal-use ar thropod repellents and permethrin-impregnated J Am Mosq Control Assoc Frances SP, Yeo AET, Brooke EW, Sweeney AW. Clothing impregnations of dibutylphthalate and permethrin as protectants against a chigger mite, Eutrombicula hirsti (Acari: Trombiculidae). J Med Ent P RO TE C TI O N O F MIL IT ARY PE RSO NNE L AG A IN S T VE C T OR -BOR NE DI S E AS E S : A RE V IE W O F C OLLABORA TI V E W OR K O F THE A US T RAL I A N A N D US MIL IT ARY O V E R THE L AS T 30 YE ARS

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October December 2016 19 11. Twartz JC, Shirai A, Selvaraju G, et al. Doxycy cline prophylaxis for human scrub typhus. J Infect Dis 12. Brown GW, Shirai A, Jegathesan A, et al. Febrile illnesses in Malaysiaan analysis of 1,629 hospital ized patients. Am J Trop Med Hyg 13. Taylor A, Kelly DJ. Scrub typhus in Malaysia. Fam Pract 14. Corcoran KD, Hansukjariya P, Sattabongkot J, et al. WR182393 (a guanylhydrazone) has causal prophy lactic and radical curative activity in the Macaca mulatta Plasmodium cynomolgi model. Am J Trop Med Hyg 15. Shanks GD, Edstein MD, Chedester AL, et al. Pro guanil plus sulfamethoxazole is not causally pro phylactic in the Macaca mulatta Plasmodium cyno molgi model. Am J Trop Med Hyg 16. Edstein MD, Corcoran KD, Shanks GD, et al. Eval causal prophylactic activity in the Plasmodium cy nomolgi Macaca mulatta model. Am J Trop Med Hyg 17. Edstein MD, Prasitthipayong A, Sabchareon A, et al. Simultaneous measurement of quinine and quinidine in human plasma, whole blood and erythrocytes by high-performance liquid chroma Ther Drug Monit 18. Keeratithakul D, Teja-Isavadharm P, Shanks GD, et al. An improved high-performance liquid chro matographic method for the simultaneous measure ment of halofantrine and desbutylhalofantrine in human serum. Ther Drug Monit 19. Edstein MD, Lika ID, Chongsuphajaisiddhi T, et al. + sulfadoxine + pyrimethamine) in human plasma by two high-performance liquid chromatographic methods. Ther Drug Monit Teja-Isavadharm P, Keeratithakul D, Watt G, et al. whole blood, and erythrocytes by high-perfor mance liquid chromatography. Ther Drug Monit 21. Nosten F, Ter Kuile F, Chongsuphajaisiddhi T, et falciparum malaria on the Thai-Myanmar border. Lancet 22. Shanks GD, Watt G, Edstein MD, et al. Halofan laxis failures. Am J Trop Med Hyg 23. cin treatment of drug-resistant falciparum malaria. J Inf Dis 24. Shanks GD, Watt G, Edstein MD, et al. Halofan trine given with food for falciparum malaria. Trans Roy Soc Trop Med Hyg 25. Ter Kuile F, Nosten F, Thieren M, et al. High-dose falciparum malaria. J Inf Dis. 26. Ter Kuile F, Dolan G, Nosten F, et al. Halofan drug resistant falciparum malaria. Lancet. 27. Frances SP, Eikarat N, Sripongsai B, Eamsila C. Response of Anopheles dirus and Aedes albopictus to repellents in the laboratory. J Am Mosq Control Assoc 28. Eamsila C, Frances SP, Strickman D. Evaluation of permethrin-treated military uniforms for personal protection against malaria in northeastern Thai land. J Am Mosq Control Assoc 29. Frances SP, Klein TA, Hildebrandt DW, et al. Labo Anopheles dirus (Diptera: Culicidae) in Thailand. J Med Entomol Frances SP, Eamsila C, Pilakasiri C, Linthicum KJ. Effectiveness of repellent formulations containing deet against mosquitoes in northeastern Thailand. J Am Mosq Control Assoc 31. Frances SP, Klein TA, Wirtz RA, et al. Plasmo dium falciparum and Plasmodium vivax circumso prozoite proteins in anophelines collected in east ern Thailand. J Med Entomol 32. Frances SP Khlaimanee N. Laboratory tests of arthropod repellents against Leptotrombidium deliense --noninfected and infected with Rickettsia tsutsugamushi --and noninfected L. (Acari: Trombiculidae). J Med Entomol 33. Frances SP, Sithiprasana R, Linthicum KJ. Re sponse of Aedes aegypti and Aedes albopictus un infected and infected with dengue virus to deet in the laboratory. J Med Entomol 34. Frances SP. Rickettsial diseases of military impor tance: an Australian perspective. J Mil Vet Hlth. 35. Frances SP, Eamsila C, Strickman D. Antibodies to Orientia tsutsugamushi in soldiers in northeastern Thailand. Southeast Asian J Trop Med Publ Hlth 36. Frances SP, Watcharapichat P, Phulsuksombati D, Tanskul P. Occurrence of Orientia tsusugamushi in rodents and chiggers (Acari: Trombiculidae) in an orchard near Bangkok, Thailand. J Med Entomol

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx37. Frances SP, Watcharapichat P, Phulsuksombati D, Tanskul P. Transmission of Orientia tsutsugamushi the aetiologic agent for scrub typhus, to co-feeding mites. Parasitol 38. Frances SP, Watcharapichat P, Phulsuksombati D. Development and persistence of antibodies to Orientia tsutsugamushi in the roof rat, Rattus rat tus and laboratory mice following attachment of naturally infected Leptotrombidium deliense Acta Tropica 39. Frances SP, Watcharapichat P, Phulsuksombati D. Vertical transmission of Orientia tsutsugamushi in two lines of naturally infected Leptotrombidium deliense (Acari: Trombiculidae). J Med Entomol Frances SP, Watcharapichat P, Phulsuksombati D, Tanskul P. Investigation of the role of Blankaartia acuscutellaris (Acari: Trombiculidae) as a vector of scrub typhus in central Thailand. Southeast Asian J Trop Med Publ Hlth 41. Coleman RE, Monkanna T, Linthicum KJ, et al. Occurrence of Orientia tsutsugamushi in small mammals from Thailand. Am J Trop Med Hyg 42. Lerdthusnee K, Khlaimanee N, Monkanna T, et Leptotrombidium chiggers (Ac ari: Trombiculidae) at transmitting Orientia tsu tsugamushi to laboratory mice. J Med Entomol 43. Phasomkusolsil S, Tanskul P, Ratanatham S, et al. Transstadial and transovarial transmission of Ori entia tsutsugamushi in Leptotrombidium imphalum and Leptotrombidium chiangraiensis (Acari: Trom biculidae). J Med Entomol 44. Phasomkusolsil S, Tanskul P, Ratanatham S, et al. Orientia tsutsugamushi infection on the developmental biology of Leptotrombidium im phalum and Leptotrombidium chiangraiensis (Acari: Trombiculidae). J Med Entomol 45. Shanks GD, Edstein MD, Suriyamongol V, et al. Malaria chemoprophylaxis using proguanil/dapsone combinations on the Thai-Cambodian border. Am J Trop Med Hyg 46. Shanks GD, Edstein MD, Kereu RK, et al. Post ex posure administration of halofantrine for the preven tion of malaria. Clin Infect Dis 47. Shanks GD, Barnett A, Edstein MD, Rieckmann KH. Effectiveness of doxycycline combined with primaquine for malaria prophylaxis. Med J Aust 48. Shanks GD, Roessler P, Edstein MD Rieckmann KH. Doxycycline for malaria prophylaxis in Austra lian soldiers deployed to United Nations missions in Somalia and Cambodia. Mil Med 49. Frances SP, Dung NV, Beebe NW, Debboun M. Field evaluation of repellent formulations against day and night-time biting mosquitoes in a tropical rainforest in northern Australia. J Med Entomol Frances SP, MacKenzie DO, Klun JA, Debboun M. against mosquitoes in Queensland, Australia. J Am Mosq Control Assoc 51. Frances SP, Cooper RD, Gupta RK, Debboun M. Ef personal protection against Anopheles farauti (Dip tera: Culicidae) in a village in Papua New Guinea. J Med Entomol 52. Kitchen LW, Lawrence KL, Coleman RE. The role of the United States military in the develop ment of vector control products, including insect repellents, insecticides, and bed nets. J Vector Ecol 53. Debboun M, Frances SP, Strickman D, eds. Insect Repellents: Principles, Methods & Uses Boca Ra 54. Strickman D, Frances SP, Debboun M. Prevention of Bug Bites, Stings, and Disease New York, NY: 55. Debboun M, Frances SP, Strickman D, eds. Insect Repellents Handbook 2nd ed. Boca Raton, FL: 56. Frances SP, Sferopoulos R, Lee B. Protection from mosquito bites provided by permethrin-treated mili tary fabrics. J Med Entomol 57. Frances SP, MacKenzie DO, Sferopoulos R, Lee treated military uniforms in Queensland, Australia. J Am Mos Control Assoc 58. an antimalarial drug in southeast Asia. Mil Med 59. monthly tafenoquine for prophylaxis of Plasmodium vivax and multi-drug resistant P falciparum malaria. J Infect Dis. Edstein MD, Kocisko DA, Walsh DS, et al. Plasma concentrations of tafenoquine, a new long-acting antimalarial agent, in Thai soldiers on monthly prophylaxis. Clin Infect Dis 61. Kocisko DA, Walsh DS, Eamsila C, Edstein MD. man plasma, and venous and capillary blood by high-pressure liquid chromatography. Ther Drug Monitor 62. Edstein MD, Koscisko DA, Brewer TG, et al. Popu lation pharmacokinetics of the new antimalaria agent tafenoquine in Thai soldiers. Br J Clin Pharmacol P RO TE C TI O N O F MIL IT ARY PE RSO NNE L AG A IN S T VE C T OR -BOR NE DI S E AS E S : A RE V IE W O F C OLLABORA TI V E W OR K O F THE A US T RAL I A N A N D US MIL IT ARY O V E R THE L AS T 30 YE ARS

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October December 2016 21 63. Haynes RK, Fugmann B, Stetter J, et al. Ar temisone-a highly active antimalarial drug of the artemisinin class. Angew Chem Int Ed Engl. 64. Obaldia N 3rd, Kotecka BM, Edstein MD, et al. Evaluation of artemisone combinations in Aotus monkeys infected with Plasmodium falciparum An timicrob Agents Chemother 65. cation of pfmdr1-containing amplicon on chromo some 5 in Plasmodium falciparum is associated with reduced resistance to artelinic acid in vitro. An timicrob Agents Chemother 66. Chavchich M, Gerena L, Peters J, et al. Role of of resistance to artemisinin derivatives in Plasmo dium falciparum Antimicrob Agents Chemother 67. Teuscher F, Gatton ML, Chen N, et al. Artemis inin-induced dormancy in plasmodium falciparum: duration, recovery rates, and implications in treat ment failure. J Infect Dis 68. Teuscher F, Chen N, Kyle DE, Gatton ML, Cheng Q. Phenotypic changes in artemisinin-resis tant Plasmodium falciparum lines in vitro: evi dence for decreased sensitivity to dormancy and growth inhibition. Antimicrob Agents Chemother 69. Edstein MD, Kotecka BM, Ager AL, et al. Antima larial pharmacodynamics and pharmacokinetics of molgus monkeys using an in vivo in vitro model. J Antimicrob Chemother Harris I, Sharrock WW, Bain LM, et al. A large proportion of asymptomatic Plasmodium infections with low and sub-microscopic parasite densities in the low transmission setting of Temotu Province, Solomon Islands: challenges for malaria diagnostics in an elimination setting. Malar J 71. Shanks GD, MD Edstein, Q Cheng, et al. Army Malaria Institute its evolution and achievements J Mil Vet Hlth Available at: http://jmvh.org/article/army-malariainstitute-its-evolution-and-achievements-fifth-de 72. Gresty K, Gray KA, Bobogare A, et al. Genetic mu tations in Plasmodium falciparum and Plasmodium vivax dihyrofolate reductase (DHFR) and dihy dropteroate synthase (DHPS) in Vanuatu and Solo mon Islands prior to the introduction of artemisinin combination therapy. Malaria J 73. Gresty K, Gray KA, Bobogare A, et al. Genetic mutations in pfcrt and pfmdr1 at a time of the arte misinin combination therapy introduction in South Malaria J AUTHORS Dr Frances is with the Australian Army Malaria Institute, Enoggera, Queensland. Dr Edstein is with the Australian Army Malaria Institute, Enoggera, Queensland. Dr Debboun is the Director of the Mosquito Control Di vision, Harris County Public Health, Houston, Texas. Dr Shanks is with the Australian Army Malaria Institute, Enoggera, Queensland. He is also a Professor at the Uni versity of Queensland School of Public Health, Brisbane, Australia.

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22 http://www.cs.amedd.army.mil/amedd_journal.aspxRickettsiae and related ehrlichial organisms are obligate lice and are the agents of numerous tick-borne diseases found in Virginia, such as Rocky Mountain spotted fever ( Rickettsia rickettsii ), Tidewater spotted fever ( Rickett sia parkeri ), Human monotropic ehrlichiosis ( Ehrlichia chaffeensis ), and Ewingii ehrlichiosis ( Ehrlichia ewin gii). These and other rickettsial diseases have affected military activities and public health throughout the world for more than 2,000 years.1 Rickettsial diseases, generally incapacitating and sometimes fatal, are fre quently unrecognized or misdiagnosed. If recognized early, they can be treated effectively with antibiotics such as doxycycline, the treatment of choice. Delayed treatment is often associated with a more serious dis ease outcome, often with complications.1In the United States, there are many tick-borne rickett siae, most of which belong to the spotted fever group of rickettsiae (SFGR). Among them are R rickettsii R parkeri Rickettisa montanensis and Rickettsia ambly ommii mans and the latter two have limited evidence suggest ing possible pathogenicity.2 Over the past few decades, many new and some previously characterized rickett siae have been found to be pathogenic.2,3 As of 2012, 26 Rickettsia species with validated and published names have been reported, the vast majority of which are con sidered tick-borne rickettsiae.2For most of the 20th century, R rickettsii the causative agent of Rocky Mountain spotted fever, was considered the only tick-borne rickettsial agent pathogenic to humans in the Americas. Rocky Mountain spotted fever (RMSF) has been consistently described as a potentially fatal disease. In the early 20th century, 63% of RMSF diagnosed patients from Montana died from the disease.4 In the late 1940s, antimicrobial therapy was developed for RMSF4 and doxycycline is now considered the drug of choice for all tick-borne rickettsial diseases in chil dren and adults.5 While the fatality rate of RMSF has diminished to 1.4% in the United States in the 21st cen tury, it is higher in South American countries (greater than 20%) despite therapy.4,6 One of the reasons for the ing the rickettsiosis. Diagnosis of RMSF is problematic the disease, which include fevers, headaches, rashes, and says.2 Recently there has been an increase in reported RMSF cases in the United States. Only 495 cases were reported to the Centers for Disease Control and Preven tion (CDC) in 2000,7 but 2,288 cases were reported in 2006 and 2,016 in 2007, marking the highest recorded levels in over 80 years.8 However, most of these cases Emerging Tick-borne Rickettsia and Ehrlichia at Joint Base Langley-Eustis, Fort Eustis, Virginia Melissa K. Miller, MS Holly Evans, PhD Ju Jiang Timothy P. Christensen, MS Melissa Truong Allen L. Richards, PhD Tamasin Yarina ABSTR A CT Four species of ticks known to parasitize humans (Amblyomma americanum (lone star tick), Dermacentor variabilis (American dog tick), Amblyomma maculatum (Gulf Coast tick), and Ixodes scapularis (black-legged tick)) were collected at Joint Base Langley-Eustis, Fort Eustis, Virginia during 2009. These ticks were tested individu ally (adults and nymphs) and in pools of 15 (larvae) for pathogens of public health importance within the genera: Rickettsia, Borrelia, and Ehrlichia, by quantitative real-time polymerase chain reaction (qPCR) assays and, where appropriate, multilocus sequence typing (MLST). Of the 340 A americanum ticks tested, a minimum of 65 (19%), 4 (1%), 4 (1%), and one (<1%) were positive for Rickettsia amblyommii, B lonestari, E ewingii and E chaffeen sis, respectively. One of 2 (50%) A maculatum ticks collected was found to be positive for R parkeri by MLST and qPCR analyses. All 33 D variabilis ticks were negative for evidence of rickettsial infections. Likewise, no pathogenic organisms were detected from the single Ixodes scapularis tick collected. Pathogenic rickettsiae and ehrlichiae are likely emerging and cause under-recognized diseases, which threaten people who live, work, train, or otherwise engage in outdoor activities at, or in the vicinity of, Fort Eustis, Virginia.

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October December 2016 23 have been described as suspect RMSF cases (ie, clini cal presentation and a single serum positive test which SFGR antibody is known to exist in about 10% of the US population.9 Thus, the presence of a single positive tive serologic reaction could represent an infection with another SFGR pathogen (eg, R parkeri R akari ) or a rickettsia of unknown pathogenicity (eg, R amblyommii R montanensis ). Thus, the lower fatality rates associated with RMSF may actually be due to the misdiagnosis of other rickettsioses with lower fatality rates than RMSF. Tidewater spotted fever, also known as Rickettsia parkeri rickettsiosis or American boutoneuse fever, has been a recently described human disease even though the causative agent, R parkeri has been known since its isolation in 1937. Ralph Robinson Parker isolated R parkeri from Amblyomma maculatum commonly known as the Gulf Coast tick. R parkeri was considered a nonpathogenic rickettsia and received little attention R parkeri human infec tion, which was similar to yet distinct from RMSF, was reported.3,10 A second case of R parkeri human infection was documented 3 years later.11 Both cases were from the Tidewater region of Virginia, in the same region as Fort Eustis. New research has also revealed that multiple tick species within the Amblyomma genus can harbor R parkeri .3,12 R parkeri human infection indicate that much is still un known about many human rickettsioses. Infection with R parkeri 2 because at least one-third of reported RMSF cases are believed to be caused by R parkeri .3,4While R parkeri species, many other rickettsiae have emerged as possible pathogens, the most notable of which is R amblyommii There have been tick bite rashes and probable RMSF cases associated with R amblyommii though none have 13,14 R amblyommii has been found in large percentages of Amblyomma americanum ticks, commonly known as lone star ticks, and is believed to be the most common rickettsia infecting A americanum ticks.13,15-17 R amblyommii and Borrelia lonestari have been suspected at one time to play a role in southern tick-associated rash illness (STARI), however the true 18-20 A americanum ticks are notoriously aggressive, nonspe tion of the continental United States.21-23 that R amblyommii is a human pathogen would be of great interest and concern. Other tick-borne obligate intracellular bacteria patho genic to humans are E chaffeensis and E ewingii mem bers of the order Rickettsiales, and agents of human monocytotropic ehrlichiosis (HME) and ewingii eh rlichiosis, respectively.21 Human monocytotropic eh rlichiosis is a mild-to-fatal febrile illness with a case fa tality rate of 2.7%.24 A majority of HME patients require hospitalization; in one HME study, 85% of patients were hospitalized and many had serious complications. Old er patients were more likely to develop complications and have longer hospitalizations.25 Ehrlichia ewingii is known to cause a mild febrile illness in humans and may account for as much as 7% of all human ehrlichiosis cas es in the United States.26 A americanum is the main vec tor of E chaffeensis and E ewingii while whitetail deer ( Odocoileus virginianus ) are the preferred vertebrate hosts of A americanum .21 Vertebrate hosts infected with ehrlichiae are bacteremic for prolonged periods,27 which increases the chance for transmission to a tick host. Human monocytotropic ehrlichiosis has been reported in 47 states, with the highest reported average annual inci dence rates in Arkansas, North Carolina, Missouri, and Oklahoma. Additionally, two-thirds of HME cases oc cur between May and July.24Fort Eustis is an approximately 3,197 hectare military in stallation located in the Tidewater region of coastal Vir ginia. Over 2,100 hectares of this property are in natural areas including pine-mixed hardwood forests, wetlands, and early successional habitat. These natural areas pro vide abundant opportunities for military training and hunting. These types of activities often center around the warmer months when many tick species are at their most active. A large component of the overall force health protection plan on Fort Eustis involves familiar ity with natural hazards such as vector-borne diseases, which may be transmitted to personnel by the bite of an infected tick. Because numerous tick-borne rickettsiae like R parkeri the etiologic agent of Tidewater spotted fever, are emerging as pathogenic bacteria, evaluation of ticks in the Fort Eustis area of Virginia was undertaken to determine the risk of tick-borne disease to residents and visitors. A large-scale surveillance effort was begun in October of 2007 to assess the tick fauna of designated portions of the property. A concise but limited portion of this effort is presented here. MA TERI A LS A ND METHODS Specimens. Questing ticks were collected from 5 preselected locations by dragging a one meter square cloth for approximately 100 meters at each site once per month from May through August 2009. Site selection was based on suitable tick habitat, and individual sites

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24 http://www.cs.amedd.army.mil/amedd_journal.aspxwere divided between areas of high human use such as golf course edges and walking trails, and low-human use such as gated natural areas. Additionally, the sites were not treated with any type of pesticide prior to or during this study. Adult and nymph ticks were L of Tis sue Lysis Buffer (Qiagen, Valencia, CA). Larvae were similarly handled with the exception that 15 larvae were placed in each 300 L of lysis buffer. Ticks were bisect ed with a sterile knife and incubated with the addition of to kit directions with the DNeasy Blood & Tissue Kit L of elution buffer. The bisected ticks, remaining lysate, ture analysis. preparations from individual (adults and nymphs) and pooled (larvae; n=15) A americanum ticks were ana lyzed for R amblyommii by the Rambl qPCR assay as previously described.16 In addition, the A americanum samples were screened for Ehrlichia species in a 20 L real-time multiplex reaction designed to amplify and differentiate a segment of the heat shock protein operon groEL of E chaffeensis and E ewingii28 using the Light Cycler FastStart DNA Master HybProbe kit (Roche) and 2 L of sample. To be determined as positive, the sam ple melting peak was compared with a known standard and only samples that had an equivalent melting tem perature were considered positive. Positive E ewingii L conven tional PCR reaction targeting the p28 gene29 using the PuReTaq Ready-To-Go PCR Beads (GE Healthcare Bio sciences, Piscataway, NJ) and 2 L of sample. Samples positive for E chaffeensis L qPCR reaction targeting the 16s rRNA sequence30 using the LightCycler TaqMan Master kit (Roche) and 5 L of sample. Borrelia lonestari infection was determined by detected a portion of the glpQ gene.31 Real-time PCR with a melting curve was performed in a 20 L reaction using LightCycler SYBR Green I master mix (Roche) and 5 L of sample. Samples that produced a melting peak and equivalent Tm to the known standard were further analyzed with a conventional PCR that ampli B lonestari .32Individual D variabilis, A maculatum and pooled or in dividual A americanum nucleic acid preparations were qPCR assay as previously described.33 The screen posi tive A maculatum nucleic acid preparation was assessed for R parkeri and Candidatus Rickettsia andeanae, as previously described.33 The single adult I scapularis (black-legged tick) was tested for Borrelia and Anaplas ma with a real-time multiplex34 using the LightCycler TaqMan Master Kit (Roche) in a 20 L reaction with 5 L of sample. Conventional PCR was performed on a MJ Research PTC 200 Thermal Cycler (Bio-Rad Laborato ries, Hercules, CA), and real-time PCR reactions were performed on the LightCycler 2.0 instrument (Roche). Standard and nested PCR assays were used to amplify outer membrane pro tein B ( ompB ) and A ( ompA ), and the surface cell anti gen 4 ( sca4 ) genes of Rickettsia .34 The master mix was composed of Platinum PCR SuperMix High Fidelity (Invitrogen), 0.3 M of primers, and one L of template. All nested PCR were followed by gel electrophoresis run on a 1.5% agarose gel at 150 volts for 30 minutes. Nested PCR products were DNA Gel Extraction Kit (Qiagen) when multiproducts were produced, 20 L of buffer was used to elute the was performed as previ ously described.35 sequenced for both strands by using the Big-Dye ter minator reagent (Applied Biosystems; Foster City, CA). Sequencing reactions were cleaned up by using gel car tridges and run on a 3130 automated sequencing ana data, Chromas software (Technelysium; Queensland, Australia) and Vector NTI software (Invitrogen; Fred rick, MD) were used. RESULTS Eight hundred sixty-one ticks (0.4 per square meter) were collected by dragging a one meter square cloth for 100 meters at each of the sample sites on each date for a total of approximately 2,000 meters. Three hundred forty A americanum 33 D variabilis and 2 A maculatum were assessed for evidence of rick ettsiae, B lonestari, E ewingii and E chaffeensis One I scapularis was assessed for Borrelia and Anaplasma species. Four hundred eighty-two A americanum larvae and 3 nymphs collected from 3 sites were not included in this study. All 4 tick species collected are considered man-biting pests and vectors of disease. EME RGING TICKBORN E RICK E TTSIA AND EH R LICHIA A T JOIN T BAS E LANG LE Y-EUS T IS, FOR T EUS T IS, VIRGINIA

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October December 2016 25 Amblyomma americanum Rickett sia Borrelia and Ehrlichia : rations from the 340 (81 single adults, 34 single nymphs, and 15 pools of larvae) A americanum ticks selected for analysis were subject to qPCR testing for R amblyom mii B lonestari E ewingii and E chaffeensis (Table 1). Borrelia lonestari was detected in 2 male and 2 female A americanum adults for an infection rate of 5% of the adults tested. Ehrlichia chaffeensis was detected in one (1%) of the adult ticks tested, and E ewingii was detected in 2 (2%) adult and 2 (6%) of the nymph samples. Nei ther of these organisms were detected in the pools of larval ticks. Rickettsia amblyommii was detected in a minimum of 65 samples, and no further analysis was performed.Dermacentor variabilis, A americanum and A macula tum Rickettsia species. Thirty three adult D variabilis, 2 female A maculatum and 340 adult and immature A americanum ticks were tested for rick ettsiae (Tables 1, 2). All D variabilis ticks were negative, however, R amblyommii was detected in a minimum of 63 A americanum ticks. Rickettsia species was detected in one of the 2 female A maculatum with the Rick17b and Rpark qPCR assays (Tables 1 and 2). Subsequently, the Rickettsia species positive DNA sample preparation from the R parkeri positive A maculatum adult tick was analyzed by multilocus sequence typing using ompA, ompB and sca4 genes. Two fragments of ompA (648 and 856 bp) and ompB (806 and 584 bp), and one frag ment of sca4 (812bp) were 100% identical to R parkeri Maculatum 20 (GenBank #AF 123717). The Candidatus Rickettsia andeanae qPCR assay (Rande) was negative for the R parkeri positive sample. The ubiquitous occur rence of A america num collected at Fort Eustis along with the aggressive man-biting character of this tick species indicates that the potential risk of rickettsial and ehrlich ial human infections could be high in the summer months in this area. An other possible public health threat is STARI, which has been documented following an A americanum tick bite.35 Even though R amblyommii and B lonestari have been suggested as possible agents of STARI, the true 18,20 An additional potential health concern associated with A americanum is the recent discovery of R parkeri in Lone Star ticks collected in Tennessee and Georgia.37 In this study, we did not detect R parkeri in any of the A americanum ticks tested. Dermacentor variabilis ticks are known to carry R rickettsii the causative agent of RMSF, and R monta nensis a rickettsia of unknown human pathogenicity.38 of D variabilis ticks assessed. This is not surprising since R rickettsii are rarely found in D variabilis even in areas highly endemic for RMSF,39 and R montanen sis is usually detected in only 5%-19% of D variabilis evaluated.9,17,38One of the 2 adult A maculatum ticks collected in this study was found to harbor R parkeri A low number of water region is not surprising since its presence in this area and throughout Virginia has only been sporadically encountered.40,41 With that said, it is interesting that 2 of R parkeri rickettsiosis cases occurred in the Tidewater area of Virginia.10-11 R parkeri was ini tially isolated from A maculatum ticks in 193742 and has recently been found in multiple Amblyomma species such as Amblyomma triste ,12 A americanum ,37,43 Ambly omma nodosum ,44 and experimentally in Amblyomma Table 1. Amblyomma americanum ticks collected by drag sampling at Joint Base Langley-Eustis, Fort Eustis, Virginia, May-August 2009.Life Stage N umber C ollected N umber Tested (N) Borrelia lonestari N umber Positive (% N ) Ehrlichia chaffeensis N umber Positive (% N ) E ewingii N umber Positive (% N ) Rickettsia amblyommii N umber Positive (% N ) Adult81 81 4 (5%) 1 (1%) 2 (2%) 34 (42%)Nymph37 34 0 (0) 0 (0) 2 (6%) 16 (47%)Larva707 225(15 pools)0 (0) 0 (0) 0 (0) 15 (7%) MIR* *Minimum infection rate, larvae tested in pools of 15 individuals. Table 2. Ticks collected by drag sampling at Joint Base Langley-Eustis, Fort Eustis, Virginia, May-August 2009.Tick S pecies Life Stage N umber C ollected N umber Tested (N) Borrelia / A naplasma N umber Positive (%N) Rickettsia S pecies N umber Positive (%N) Rickettsia parkeri N umber Positive (%N) Amblyomma maculatum Adult2 2Not tested1 (50%) 1 (50%)Dermacentor variabilis Adult33 33Not tested0 (0) 0 (0)Ixodes scapularis Adult1 1 0 (0)Not tested Not tested

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26 http://www.cs.amedd.army.mil/amedd_journal.aspxcajennense .45 The discovery of R parkeri infected ticks at Fort Eustis (in the Tidewater region of Virginia) com bined with 2 Tidewater R parkeri human infections10,11 from the same region implies that residents of and visi tors to the Tidewater area may be at risk of R parkeri infections. In addition, A maculatum endemic to the southern United States,40,41,46 may be widening its geo graphic range, implying that the geographic range of R parkeri is expanding as well. If the endemic region of A maculatum and R parkeri are growing, healthcare pro viders should be made aware of possible R parkeri rick ettsiosis in their areas, and that Tidewater spotted fever has been confused for RMSF.4 The results of this study reveal the need to learn more about the distribution of this vector in the Tidewater region, the prevalence of R parkeri infection of the Gulf Coast tick, and the inci dence of Tidewater spotted fever in this area. The inherent sampling bias of the cloth drag method is well explained by Schulze et al.47 However, in this instance it was employed as a surrogate to estimate rates at which a human may encounter ticks at Fort Eustis. Based on this assessment, the potential exists to encounter at least 4 ticks per 10 meters traveled on foot in natural, training, and recreational areas at Fort Eustis. Furthermore, pathogenic R parkeri, E ewingii and E chaffeensis which pose a risk to human health in and nymph ticks collected from Fort Eustis. The pre dicted rate of encounter of an infected adult or nymph tick may be as high as 5 infected ticks per 100 meters traveled. Human rickettsial and ehrlichial diseases in cluding RMSF and HME1 may be misdiagnosed due to their often cryptic symp toms. Since R parkeri has been recognized as a human pathogen only for the past few years, there is an even greater chance of misdiagnosis of R parkeri rickettsio sis. Indeed, one-third of supposed RMSF cases are be lieved to be misdiagnosed R parkeri cases.4 Clinicians, therefore, should be aware of this condition. Moreover, studies are needed to determine the occurrence, distri bution, and seasonality of A maculatum and R parkeri in the mid-Atlantic states of North Carolina, Virginia, and Maryland, which were previously not known to have long-established populations of A maculatum Likewise, E chaffeensis and E ewingii the discoveries of which occurred in 1986 and 1999, respectively, are also rela tively unknown agents associated with the underreport ed disease HME and ewingii ehrlichiosis.24,25 Location of the diseases and their arthropod vectors are essential in informing medical health care providers, preventive medicine personnel, and the general population as to the risk of tick-borne diseases.48 ACKNOWLEDGE M ENT This work was supported by the Department of Defense Global Emerging Infections System program work unit # 847705.82000.25GB.A0074. The authors thank Ben Pagac for his review of this manuscript. REFERENCES 1. Kelly DJ, Richards AL, Temenak J, Strickman D, Dasch GA. The past and present threat of rickett sial diseases to military medicine and international public health. Clin Infect Dis 2002;34:145-169. 2. Parola P, Paddock CD, Socolovschi C, et al. Up date on tick-borne rickettsioses around the world: a geographic approach. Clin Microbiol Rev 2013;26:657-702. 3. Parola P, Labruna MB, Raoult D. Tick-borne rickettsioses in America: unanswered ques tions and emerging diseases. Curr Infect Dis Rep 2009;11:40-50. 4. Raoult D, Parola P. Rocky Mountain spotted fever in the USA: a benign disease or a common diagnos tic error?. Lancet Infect Dis 2008;8:587-589. 5. Chapman AS, Bakken JS, Folk SM, et al; Tick borne Rickettsial Working Group; CDC. Diagno sis and management of tickborne rickettsial dis eases: Rocky Mountain spotted fever, ehrlichio ses, and anaplasmosis-United States: a practical guide for physicians and other health-care and public health professionals. MMWR Recomm Rep 2006;55(RR-4):1-27. 6. Paddock CD, Fernandez S, Echenique GA, Sumner JW, Reeves WK, Zaki SR, Remondegui CE. Rocky Mountain spotted fever in Argentina. Am J Trop Med Hyg 2008;78:687-692. 7. Ammerman NC, Swanson KI, Anderson JM, Schwartz TR, Seaberg EC, Glass GE, Norris DE. Spotted-fever group Rickettsia in Derma centor variabilis Maryland. Emerg Infect Dis 2004;10:1478-1481. 8. Walker DH, Paddock CD, Dumler JS. Emerg ing and re-emerging tick-transmitted rickett sial and ehrlichial infections. Med Clin North Am 2008;92:1345-1361. 9. Graf PCF, Chretien JP, Ung L, Gaydos JC, Rich ards AL. Prevalence of seropositivity to spotted fever group rickettsiae and Anaplasma phagocy tophilum in a large, demographically diverse US sample. Clin Infect Dis 2008;46:70-77. 10. Paddock CD, Sumner JW, Comer JA, et al. Rick ettsia parkeri : a newly recognized cause of spotted fever rickettsiosis in the United States. Clin Infect Dis 2004;38:805-811.EME RGING TICKBORN E RICK E TTSIA AND EH R LICHIA A T JOIN T BAS E LANG LE Y-EUS T IS, FOR T EUS T IS, VIRGINIA

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October December 2016 27 11. Whitman TJ, Richards AL, Paddock CD, et al. Rickettsia parkeri infection after tick bite, Virginia. Emerg Infect Dis 2007;13:334-336. 12. Romer Y, Nava S, Govedic F, et al. Rickettsia parkeri rickettsiosis in different ecological regions of Argentina and its association with Amblyomma tigrinum as a potential vector. Am J Trop Med Hyg 2014;91:1156-1160. 13. Apperson CS, Engber B, Nicholson WL, et al. Tickborne diseases in North Carolina: is Rickettsia amblyommii a possible cause of rickettsiosis re ported as Rocky Mountain spotted fever? Vector Borne Zoonotic Dis 2008;8:597-606. 14. Billeter SA, Blanton HL, Little SE, Levy MG, Bre itschwerdt EB. Detection of Rickettsia amblyommii in association with a tick bite rash. Vector Borne Zoonotic Dis 2007;7:607-610. 15. Mixson TR, Campbell SR, Gill JS, Ginsberg HS, Reichard MV, Schulze TL, Dasch GA. Prevalence of Ehrlichia Borrelia and rickettsial agents in Am blyomma americanum (Acari: Ixodidae) collected from nine states. J Med Entomol 2006;43:1261-1268. 16. Jiang J, Yarina T, Miller MK,Stromdahl EY, Rich ards AL. Molecular detection of Rickettsia ambly ommii in Amblyomma americanum parasitizing hu mans. Vector Borne Zoonotic Dis 2010;10:329-340. 17. Smith MP, Ponnusamy L, Jiang J, Ayyash LA, Richards AL, Apperson CS. Bacterial pathogens in ixodid ticks from a Piedmont County in North Carolina: prevalence of rickettsial organisms. Vec tor Borne Zoonotic Dis 2010;10:939-952. 18. Masters EJ, Grigery CN, Masters RW. STARI, or Masters disease: Lone Star tick-vectored Lyme-like illness. Infect Dis Clin North Am 2008;22:361-376,viii. 19. James AM, Liveris D, Wormser GP, Schwartz I, Montecalvo MA, Johnson BJ. Borrelia lonestari infection after a bite by an Amblyomma america num tick. J Infect Dis 2001;183:1810-1814. 20. Armstrong PM, Brunet LR, Spielman A, Telford SR III. Risk of Lyme disease: perceptions of resi dents of a Lone Star tick-infested community. Bull World Health Organ 2001;79:916-925. 21. Childs JE, Paddock CD. The ascendancy of Ambly omma americanum as a vector of pathogens affect ing humans in the United States. Annu Rev Ento mol 2003;48:307-337. 22. Merten HA, Durden LA. A state-by-state survey of ticks recorded from humans in the United States. J Vector Ecol 2000;25:102-113. 23. Goddard J, Varela-Stokes AS. Role of the lone star tick, Amblyomma americanum (L.), in human and animal diseases. Vet Parasitol 2009;160:1-12. 24. McQuiston JH, Paddock CD, Holman RC, Childs JE. The human ehrlichioses in the United States. Emerg Infect Dis 1999;5:635-642. 25. Eng TR, Harkess JR, Fishbein DB, Dawson JE, Greene CN, Redus MA, Satalowich FT. Epide man ehrlichiosis in the United States, 1988. JAMA 1990;264:2251-2258. 26. Buller RS, Arens M, Hmiel SP, et al. Ehrlichia ew ingii a newly recognized agent of human ehrlichio sis. N Engl J Med 1999;341:148-155. 27. Davidson WR, Lockhart JM, Stallknecht DE, Howerth EW, Dawson JE, Rechav Y. Persistent Eh rlichia chaffeensis infection in white-tailed deer. J Wildl Dis 2001;37:538-546. 28. Bell C, Patel R. A real-time combined polymerase chain reaction assay for the rapid detection and dif ferentiation of Anaplasma phagocytophilum Eh rlichia chaffeensis, and Ehrlichia ewingii Diagn Microbiol Infect Dis 2005;53:301-306. 29. cation of a p8 gene in Ehrlichia ewingii: Evalu ation of gene for use as a target for a speciesJ Clin Microbiol 2001;39:3871-3876. 30. Loftis AD, Massung RF, Levin ML. Quantitative real-time PCR assay for detection of Ehrlichia chaffeensis. J Clin Microbiol 2003;41:3870-3872. 31. Bacon RM, Pilgard MA, Johnson BJB, Piesman J, Biggerstaff BJ, Quintana M. Rapid detection methods and prevalence estimation for Borrelia lonestari glpQ in Amblyomma americanum (Acari: Ixodidae) pools of unequal size. Vector Borne Zoo notic Dis 2005;5:146-156. 32. Barbour AG, Maupin GO, Teltow GJ, Carter CJ. Bor relia species in the hard tick Amblyomma america num : Possible agent of a Lyme disease-like illness. J Infect Dis 1996;173:403-409. 33. Jiang J, Stromdahl EY, Richards AL. Detection of Rickettsia parkeri and Rickettsia andeanae in Amblyomma maculatum Gulf Coast ticks collected from humans, USA. Vector Borne Zoonotic Dis 2012;12:175-182. 34. Courtney JW, Kostelnik LM, Zeidner NS, Mas sung RF. Multiplex real-time PCR for detection of Anaplasma phagocytophilum and Borrelia burg dorferi. J Clin Microbiol 2004;42:3164-3168. 35. Jiang J, Blair PJ, Felices V, et al. Phylogenetic analysis of a novel molecular isolate of spotted fever group rickettsiae from northern Peru: Can didatus Rickettsia andeanae. Ann NY Acad Sci 2005;1063:337-342.

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28 http://www.cs.amedd.army.mil/amedd_journal.aspx36. Barbour AG, Maupin GO, Teltow GJ, Carter CJ. Bor relia species in the hard tick Amblyomma america num : possible agent of a Lyme disease-like illness. J Infect Dis 1996;173:403-409. 37. Cohen SB, Yabsley MJ, Garrison LE, et al. Rick ettsia parkeri in Amblyomma americanum ticks, Tennessee and Georgia, USA. Emerg Infect Dis 2009;15:1471-1473. 38. Bell EJ, Kohls GM, Stoenner HG, Lackman DB. Nonpathogenic rickettsias related to the spotted fever group isolated from ticks, Dermacentor vari abilis and Dermacentor andersoni from eastern Montana. J Immunol 1963;90:770-781. 39. Stromdahl EY, Vince M, Jiang J, Richards AL. In frequency of Rickettsia rickettsii in Dermacentor variabilis removed from humans. Vector Borne Zoonotic Dis 2011;11:969-977. 40. Sonenshine DE, Lamb JT Jr, Anastos G. The distri bution, hosts and seasonal activity of Virginia ticks. Virginia J Sci 1965;16:26-91. 41. Teel PD, Ketchum HR, Mock DE, Wright RE, Strey OF. The Gulf Coast tick: a review of the life history, ecology, distribution, and emergence as an arthropod of medical and veterinary importance. J Med Entomol 2010;47:707-722. 42. Parker RR, Kohls GM, Cox GW, Davis GE. Ob servations on an infectious agent from Amblyomma maculatum Public Health Rep 1939;54:1482-1484. 43. Goddard J, Norment BR. Spotted fever group rickettsiae in the lone star tick, Amblyomma americanum (Acari: Ixodidae). J Med Entomol 1986;23:465-472. 44. Ogrzewalska M, Pacheco RC, Uezu A, Richt zenhain LJ, Ferreira F, Labruna MB. Rickettsial infection in Amblyomma nodosum ticks (Acari: Ixodidae) from Brazil. Ann Trop Med Parasitol 2009;103:413-425. 45. Sangioni LA, Horta MC, Vianna MCB, et al. Rick ettsial infection in animals and Brazilian spotted fe ver endemicity. Emerg Infect Dis 2005;11:265-270. 46. Estrada-Pena A, Venzal JM, Mangold AJ, Cafrune MM, Guglielmone AA. The Amblyomma macula tum Koch, 1844 (Acari: Ixodidae: Amblyomminae) tick group: diagnostic characters, description of the larva of A. parvitarsum Neumann, 1901, 16S rDNA sequences, distribution and hosts. Syst Parasitol 2005;60:99-112. 47. Schulze TL, Jordan RA, Schulze CJ, Mixson T, Pa pero M. Relative encounter frequencies and preva lence of selected Borrelia, Ehrlichia, Anaplasma infections in Amblyomma americanum and Ixodes scapularis (Acari: Ixodidae) ticks from central New Jersey. J Med Entomol 2005;42:450-456. 48. Feder HM Jr, Hoss DM, Zemel L, Telford SR III, Dias F, Wormser GP. Southern tick-associated rash illness (STARI) in the north: STARI following a tick bite in Long Island, New York. Clin Infect Dis 2011;53(10):e142-e146. AUTHORS Ms Miller is an entomologist and Chief, Laboratory Sci ences Division, Public Health Command Region-North, Fort Meade, Maryland. Ms Jiang is a rickettsiologist in charge of laboratory de agents in the Rickettsial Diseases Research Program, Vi ral and Rickettsial Diseases Department, Naval Medical Research Center, Silver Spring, Maryland. Ms Truong is an investment banking analyst at Stifel Nicolaus Weisel. She received a BS in Biology (Physi ology and Neurobiology) and a BS in Finance from the University of Maryland, College Park, Maryland. Ms Yarina is a microbiologist and currently a Masters of Public Health candidate focusing on epidemiology at George Washington University, Washington, DC. Dr Evans is a postdoctoral fellow in the laboratory of Dr Edward Mitre, Department of Microbiology and Im munology, Uniformed Services University, Bethesda, Maryland. Mr Christensen is a biological scientist overseeing the natural resources and entomology programs for Joint Base Langley-Eustis, Fort Eustis and assigned to the En vironmental Element, Civil Engineer Division, 733 Mis sion Support Group, Fort Eustis, Virginia. Dr Richards is a senior scientist and rickettsiologist, in charge of the Rickettsial Diseases Research Program, Viral and Rickettsial Diseases Department, Naval Medi cal Research Center, Silver Spring, MD. He is also an adjunct professor of the Emerging Infectious Diseases program and Preventive Medicine and Biometrics De partment, Uniformed Services University of the Health Sciences, Bethesda, Maryland.EME RGING TICKBORN E RICK E TTSIA AND EH R LICHIA A T JOIN T BAS E LANG LE Y-EUS T IS, FOR T EUS T IS, VIRGINIA

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October December 2016 29Hymenoptera envenomization poses an environmental threat during military contingency operations and ven om hypersensitivity can pose a serious health hazard.1 Army Regulation 40-5012 lists anaphylaxis to arthropod stings as a disqualifying medical condition. The US Army Medical Command issued a stinging insect pol icy providing additional assessment and management guidance of Soldiers with a possible allergy to stings.3 The Navy and Marine Corps follow guidelines in the Manual of the Medical Department4 which states that a current history of severe allergic reaction, anaphylax is, or life threatening manifestations to environmental substances is a disqualifying condition for active duty service. Allergies that require allergy immunotherapy are also disqualifying unless a period of desensitization can be accomplished during a period of limited duty. However, there are medical or administrative waivers to gain entry into the US armed forces. In these cases, venom hypersensitivity must be clearly denoted on per sonnel medical documents, and medical/pharmacy de partments are to ensure service members are equipped with epinephrine auto-injectors, especially during pre deployment health screenings. Physicians can also issue service members with documented hypersensitivity to insect stings a medical warning tag per Bureau of Medi cine and Surgery Instruction 6150.35 .5 work, allergic reactions to Hymenoptera stings can be especially challenging, particularly since a history of allergic reactions to stings is many times not known pre vious to exposure. In the United States, half of all fatal reactions reportedly occur with no history of previous sting reactions.6 Navy corpsman or an Army medic with a small supply of medicines and equipment may be the only healthcare providers available. The standard medical bag carried ships includes an epinephrine auto-injector (eg, EpiPen). For Navy Corpsman who work directly with operational units, including but not limited to Marines, Seabees, or other special operations, medical records are reviewed prior to any deployment or exercise. This is done to get a brief medical overview of the personnel they are respon sible for, and ensure that proper medication is on hand in case of anaphylactic emergencies. Following instruc tions provided in the US Navy Manual of the Medical Department ,4 man will ensure that the service member who has an al lergy to Hymenoptera stings has an epinephrine auto-in jector issued to them and inspect to ensure the member possesses it before deployment. Individual commands may also write local instructions and policies specifying when it is mandatory for members to carry an EpiPen. This could also be a written directive from the members healthcare provider issuing the prescription ( Manual of the Medical Department4 Article 21-4). Directions ac companying an EpiPen also state that the device should be carried with the patient.Honey Bee Swarms Aboard the USNS Comfort : Recommendations for Sting Prevention, Swarm Removal, and Medical Readiness on Military Ships LCDR James C. Dunford, MSC, USN CDR Karl C. Kronmann, MC, USN HM1 Luke R. Peet, USN CAPT (Sel) Jeffrey D. Stancil, MSC, USN ABSTR A CT The article provides observations of multiple honey bee ( Apis mellifera ) swarms aboard the USNS Comfort (TAH-20) during the Continuing Promise 2015 mission. A brief overview of swarming biology is given along with control/removal recommendations to reduce sting exposures. The observations suggest that preven tive medicine personnel should provide adequate risk communications about the potential occurrence of bee swarms aboard military ships, and medical department personnel should be prepared for the possibility of treating of multiple sting exposures, especially in the Southern Command Area of Operations where the Afri canized genotype of A mellifera is common.

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30 http://www.cs.amedd.army.mil/amedd_journal.aspxHymenoptera, the order of insects comprised of bees, hornets, wasps, and ants, tend to be more aggressive and apt to sting when there is greater sociality within a species.7 Social or semisocial bees that live in colonies, especially near man-made structures, increase the risk of sting exposures for 2 primary reasons: Social bees are more sensitive to perceived threats in order to protect brood and food resources in the hive. Humans tend to prefer not to have them in close proximity and make efforts, often using coun terproductive means, to rid the area of nesting or swarming bees. During a 2010 deployment in support of Operation En during Freedom, a study was conducted to determine the prevalence of insect stings and venom hypersensitivity in military personnel operating in Afghanistan.1,8 Three species most commonly encountered by military person nel included social species in the superfamilies Apoidea (bees) and Vespodiea (wasps): Polistes wattii Cameron, Vespula germanica (Fabricius), and Vespa orientalis Linnaeus. These species were frequently observed near man-made structures located on military installations. Highly social honey bee ( Apis mellifera L.) colonies swarm for a variety of reasons. These swarms usually occur when bees move from one location to another to search for a site to construct a new hive, which is a natural means of honey bee reproduction. Swarming is initi ated when the queen bee leaves the original hive with the rest of the colony following her movements. Because ing the remainder of the colony stop along the way to new nesting sites. The swarming season is typically a 4-6 week period and occurs in the late spring or early summer, but this may vary due to geographical location. Bees moving in the swarm tend to be less aggressive as there are no immatures (brood) to tend to or food to protect; however, because these bees are protecting the queen, any perceived threat may trigger an alarm phero mone resulting in bee stings to anything nearby. This may be especially important in the Southern Command Area of Operations (SOUTHCOM AOR) where the Af ricanized genotype of A mellifera is more prevalent. As of 2012, established populations of Africanized honey bees were found in every country in Central and South America except Chile.9Africanized honey bees respond to food shortages by migrating and make small to large colonies that repro duce (swarm) often, ranging from 4-8 times a year.10 It is unclear if Africanized honey bees were encountered during the Continuing Promise 2015 mission discussed in this article because they are morphologically indis tinguishable (without morphometric calculations) from the European honey bee. However, one key difference is that the Africanized genotype tends to swarm more commonly than the European genotype due to frequent hive overcrowding.9 Africanized honey bees are also ag gressively protective of their young and respond quickly by viciously stinging a suspected intruder and may at tack more than 5 feet from the nest. It has also been noted that strong equipment vibration can activate Afri canized honey bees from a distance of greater than 100 feet.11 There is detailed biological and behavioral infor mation on bee swarming in the literature and in various extension publications12,13; thus, swarming behavior is not covered in great detail here. The presence of bees or bee swarms may be an over looked force health protection issue aboard ships while underway or in port. We report here the occurrence of at least 4 bee swarms and numerous honey bee reports aboard ship while deployed with the USNS Comfort (TAH-20) in support of the humanitarian mission Con tinuing Promise 2015, which was conducted throughout much of the SOUTHCOM AOR. For this deployment, an entomologist was onboard to provide guidance on how best to manage the presence of bees to prevent sting exposures; however, supplies were not available to re move bees if required. Personnel on less well-informed ships may sustain unnecessary stings due to inappro priate removal tactics and lack of knowledge about bee behaviors. This may be especially important on ships without adequate medical services to respond to severe sting reactions. Upon conducting a literature search using Google on line search terms honey bee, swarms, Navy, mil bee swarming aboard military ships. While bee swarm ing has apparently not been previously documented, it is not a new phenomenon. Along with our observations aboard USNS Comfort we have received other anec dotal reports of bee swarms aboard various seafaring vessels including previous missions aboard the Comfort Bee swarms were observed on USS Iwo Jima (LHD-7) on a forklift as shown in Figure 1 during Continuing Promise 2010 (R. Flores, written communication), and on USNS Comfort during Continuing Promise 2011 as observed by author J. D. Stancil. In 2014, a large bee swarm was observed on a crash and salvage crane aboard the USS Peleliu (LHA-5) while pierside in the Republic of Philippines (C. Guckeyson, written com munication) (Figure 2). Navy Environmental and Pre ventive Medicine Unit-6 (NEPMU-6) preventive medi cine personnel responded to swarms aboard USS Preble HO N EY BEE SW ARMS A BO ARD T H E USNS COMFORT : RECOMM E N D A TIONS FOR STI N G P R EVE N TIO N SW ARM RE M OV A L, AN D MEDIC A L RE A DIN E SS O N MILIT AR Y S HIPS

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October December 2016 31 (DDG-88) and USS Port Royal (CG-73) while the ships were in port in Pearl Harbor, Hawaii, in 2014 (E. Gerar do, written communication). To the best of our knowl document this phenomenon and develop hypotheses as to why it occurs aboard ships. In this note, we document our observations, provide recommendations to prevent sting exposures, and offer solutions to the safe removal of bees during shipboard operations. We hope this leads to a better understanding of bee swarming behavior and the ability of shipboard personnel to prepare for this po tential health risk. HONEY BEE OBSERV A TIONS During the Continuing Promise 2015 mission, bee swarms on the USNS Comfort anchor near the coast of Guatemala on April 23, 2015. Within 2 days after dropping anchor approximately 8 miles off the coast of the port city Puerto Barrios, a bee swarm was reported near the ships bridge. The swarm was encompassing a utility box covering a thermometer located on the bridge (Figure 3). The bees were not ag gressive, although at least one sting was reported. Many of the bees were vibrating their wings, likely in an at tempt to regulate the ambient temperature for the queen and maneuvered around the box to avoid being in direct sunlight. Rapid wing vibrations may also have been a result of worker bees releasing pheromones using their wings to disseminate chemicals to orient forager bees back to the colony. The total number of bees slowly de clined until all bees had left the area within 48 hours of initial reports. There were also numerous individual bees reported in many areas of the ship throughout the time it was anchored at this location. These may have been scout bees from the swarm looking for a suitable place to nest. At least 3 bee swarms were again noted while pierside in Acajutla, El Salvador, starting on June 17. Swarms were cated on an antenna located towards the bow (forward) (Figure 4) on June 17, an air conditioning unit towards the stern of the ship (aft) (Figure 5) on June 18, and the base of an aft antenna (Figure 6) on June 19. The bee swarm located on the forward antennae departed within group moved to different locations noted for the other 2 sightings. The bee swarm located on the aft air condi tioning unit remained until June 21, but the number of bees appeared to decline daily from initial reports. In Figure 1. Bee swarm (red arrow) on a forklift aboard the USS Iwo Jima (LHD-7). Image courtesy of HM1 Robert Flores. Figure 2. Bee swarm (red box) on crash and salvage crane aboard the USS Peleliu (LHA-5). Photo courtesy of HMC Chris Guckeyson.

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32 http://www.cs.amedd.army.mil/amedd_journal.aspxaddition, this location on the upper portion of the ship had numerous dead bees located near the air condition ing units. The bee swarm located on the aft antenna on June 18 had departed by June 21. Although no swarms were observed, numerous individual bee sightings and complaints were also made aboard ship at a port stop in Coln, Panama, between June 30 and July 5. MEDIC A L RE P ORTING OF HY M ENO P TER A STINGS We mined medical records in the ships log for any re ported Hymenoptera stings or suspected allergic reac tions to bee stings. During the mission, 7 patients re ported to sick bay for arthropod-related stings or bites. spider bites, and two were attributed to bee stings. One of the bee stings was reported on April 28 by a civil mariner, and an active duty service member reported HO N EY BEE SW ARMS A BO ARD T H E USNS COMFORT : RECOMM E N D A TIONS FOR STI N G P R EVE N TIO N SW ARM RE M OV A L, AN D MEDIC A L RE A DIN E SS O N MILIT AR Y S HIPS Figure 3. Bee swarm on thermometer box aboard USNS Com fort (TAH-20) off the coast of Guatemala. Photo provided by LCDR J. Dunford. Figure 5. Bee swarm on air conditioning unit aboard USNS Comfort (TAH20) in port in Acajutla, El Salvador. Photo cour tesy of LCDR J. Dunford. Figure 6. Bee swarm on base of aft antenna aboard USNS Comfort (TAH20) in port in Acajutla, El Salvador. Photo cour tesy of HM1 L. Peet. Figure 4. Bee swarm (red box) on antenna aboard USNS Com fort (TAH-20) in port in Acajutla, El Salvador. Photo courtesy of LCDR J. Dunford.

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October December 2016 33 the other bee sting June 18. The bee stings were report ed during mission stops (Guatemala and El Salvador) in which bee swarms were observed aboard ship. No seri ous reactions were reported for any of the arthropodrelated stings or bites. RECO MM END A TIONS Most bee swarms, especially aboard a ship where no proximity, will leave on their own in a few hours or days. Accordingly, a simple rule of thumb is to not panic, and maintain a safe distance from the swarm. Many sting exposures are due to unnecessary aggravation of the swarm, such as throwing objects or spraying various substances in an attempt to get them to move on. Bees are typically docile during swarming unless provoked by an inappropriate attempt to rid the area of the swarm. but this is not recommended. Insecticide applications may provoke the bees, and is completely unnecessary unless the bee swarm appears to be building cells for nesting or where operational commitments dictate im mediate bee removal. If a swarm cannot be allowed to professional bee removal service to remove and safely relocate the swarm. However, this option is typically not possible during shipboard contingency missions unless a local vendor is available for hire while in port. We recommend contacting the US Embassy in the port country to determine if a suitable vendor is available and has been vetted for pest control services. Because of the value of honey bees in crop production, bee removal is often done for free or for a minimal charge. This may be a viable option while in port, especially in the United States, for long periods of time. Local farmers and na tional beekeepers associations may also be contacted for bee removal services. During contingency missions or in foreign ports, espe cially those in the SOUTHCOM AOR where the Afri canized honey bee genotype is more prevalent, we rec ommend reporting bee swarms immediately to preven tive medicine personnel. They should then work with the appropriate shipboard personnel to set up a safe perimeter around the bee swarm until it departs. Based on author J. C. Dunfords observations of bee swarm be havior aboard the USNS Comfort a safe perimeter is at least 25 feet from the swarm as illustrated in Figure 7. It should be noted that Africanized honey bees can perceive threats 50 feet or more away from their nest; however, swarms tend to be more docile. The perim eter should be clearly marked with Do Not Enter signs along with information about the presence of a bee swarm. This area should then be checked periodically by preventive medicine or other informed personnel un til the swarm has moved on. During Continuing Prom ise 2015, the ships Master at Arms played an important role in locating bee swarms, reporting, and directing his personnel to follow the recommendations of the Direc torate for Public Health. Keeping personnel a safe dis tance away from swarms not only prevents intentional exposure (eg, during inadequate attempts to remove the bees), but also accidental exposure, as we found that in many cases individuals transiting the decks were not aware of the presence of the bees. Operating equipment that creates strong vibrations near a bee swarm is also not advisable as this may trigger the bees to react to perceived danger. Although the swarm is likely to depart its temporary resting site within a few hours or days, the swarms loca tion may hinder operational duties or may be located in a space frequented by personnel that require access to it. In addition, if scout bees leaving the swarm are unable Figure 7. Civil mariner blocking area with bee swarm (red box) on base of antenna (also shown in Figure 4) aboard USNS Comfort (TAH-20) in port in Acajutla, El Salvador. Photo cour tesy of LCDR J. Dunford.

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx struction of their combs on a structure on which they have clustered, even though this would not be optimal for the colony on a ship. For the bees, a suitable nesting location may be an area well protected from the elements, receive a certain amount of warmth from the sun, and be 15 liters in volume. When these circumstances exist, there may be no other option but to destroy the swarm to prevent sting exposures. We recommend that preven tive medicine units consider procuring a beekeeping suit for shipboard missions, especially in the SOUTHCOM AOR, as part of their entomological equipment build, as it is the only effective means to protect personnel ap plying insecticides or attempting to relocate a swarm, especially Africanized honey bee swarms. If feasible, relocation of the colony is possible by following tech niques often used by beekeepers but should be done so only with proper personal protective equipment (ie, full heat stress issues) ensuring all exposed skin is covered and gaps between the head gear, suit, gloves, and boots are sealed (or tucked in) using rubber bands, Velcro, or duct tape. Beekeepers may use traps baited with Nasonov phero mone to attract swarming bees. This naturally occur ring pheromone consists of several terpenoids and is used to orient foraging bees back to the colony. Other capture methods include using a bee vacuum or equiva lent with enough suction to collect all of the bees in a container to keep them from escaping after being cap tured. A suitable box with a small opening called a nuc (similar to empty beehive) can also be used. If a bee swarm is encountered, a white sheet can be placed under the swarm location with a nuc box placed on the middle of the sheet. The swarm can be sprayed with a sugar solution and then shaken or scrapped off the resting sur face into the nuc. If the queen does enter the nuc, most of the remaining colony will follow soon thereafter. This capture method can only be performed during the day and should be done wearing personal protective equip ment described earlier. As a last option, insecticides approved for bee control can be used to destroy the swarming colony. Given the recent decline in bee populations in many parts of the world, we do not recommend destroying honey bee colo nies; however, mission objectives may require this ac tion. Department of Defense approved pesticides should be used strictly following label instructions and used quired following insecticide label). A current list of ap proved pesticides can be found at the Armed Forces Pest Management Board web site (http://www.acq.osd.mil/ eie/afpmb/). All personnel, including onlookers, should be adequately protected or clear of the area to prevent bee sting exposures during insecticide applications. In secticides should be applied directly to the swarm and dead bees should be removed from the area and discard ed. As an alternative, spraying soapy water (one cup of liquid dishwashing detergent per gallon of water) in a high volume spray may also be used and applied using maximum personnel protective gear such as a beekeep ing suit. Preventive medicine personnel from NEPMU-6 responding to a bee swarm aboard the USS Port Royal used this technique to successfully neutralize over 1,000 bees (E. Gerardo, written communication). Other sur 14In the unfortunate case that bees are attacking, person nel must exit the area as quickly as possible. Africanized honey bees will continue to defend their nest for a dis tance of a mile or more; thus, it is important to protect the head, eyes, nose, and mouth with hands, arms, or clothing. Enter a sheltered area to get away from the ma jority of the swarm and seek medical attention if stung. The lethal dose of bee venom for a human is approxi mately 10 stings per pound of body weight.10 If one or knife, or credit card are warranted. The patient should then be monitored for any signs of anaphylaxis. Bet ten et al15 consider a massive attack to be 50 stings or more. When the number of stings is less than 50, and the victim is not hypersensitive to the venom and properly treated, conservative, supportive care is appropriate.9 It should be noted that about half of the people who have anaphylactic reactions to bees stings do not have a his questioned about warning symptoms such as develop are not always recognized immediately due to the dis traction of the painful stings. Although the toxicity of Africanized honey bees is simi lar to the European honey bee, multiple stings in a short period of time can cause severe allergic reactions. Mas sive envenomization is rare, and treatment of severe al lergic reactions includes management of shock, hypox ia, and other effects on the organs. Personnel with no known bee allergies are still at risk for systemic anaphy laxis as discussed above, which may be exacerbated by multiple bee stings16 which is often seen when attacked by Africanized honey bees. Although rare, strokes have also been reported following multiple bee stings.17 The HO N EY BEE SW ARMS A BO ARD T H E USNS COMFORT : RECOMM E N D A TIONS FOR STI N G P R EVE N TIO N SW ARM RE M OV A L, AN D MEDIC A L RE A DIN E SS O N MILIT AR Y S HIPS

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October December 2016 35 cosmopolitan distribution and prevalence of A mellifera (and Hymenoptera in general) increases the likelihood that adults have had previous sting exposures to various genotypes of this species. Based on studies evaluating the cross-reactivity of insect venoms, it can be assumed that closely related species would likely pose a greater threat to an individual with previous sting exposures during ones lifetime18,19; thus, insect venom hypersensi tivity in service members should be closely and continuously monitored. Predeployment questionnaires during overseas health screenings should clearly denote known history of Hymenoptera venom sensitivity and treat ment should be available. Medical departments should also ensure readiness for bee stings including protocols to treat massive envenomization or patients with hyper sensitivity to Hymenoptera venom. Upon embarkation, the USNS Comfort had 8 EpiPen injectors available for use, in addition to aqueous epinephrine stocked in the ships pharmacy. While the Comfort has a well-supplied pharmacy, there are no formal instructions on how other vessels should be stocked. Predeployment force health protection briefs should include awareness of stinging insects and emphasize avoidance measures to limit con tact with potentially aggressive Africanized honey bee colonies. CO MM ENT During Continuing Promise 2015, bee encounters were the most numerous arthropod-related complaints from crew aboard ship. Bees apparently use ships as an in build a new hive, and we speculate that bee swarms may other mechanical equipment aboard ship. There were several areas on the ship where vibrations, heat, visual, or olfactory emissions may have attracted swarming colonies. Air conditioning units on the ship vibrate and radio antennas may also transmit vibrations via subtle wavelengths; bee swarms were noted at both such loca tions during Continuing Promise 2015. Gilbert et al20 selection in honey bees by enhancing scouting and re cruitment. Vibration signal activity and recruitment or waggle dances are known to play a role in colony liftoff preparations and swarm movement within colonies.21 A primary function of these signals during house-hunting may be to generate a level of activity in workers that co ordinates responses that stimulate departure and move ment to new nesting locations. It is unclear if subtle vi brations transmitted by equipment on the ship played a role in attracting or interfering with the colonys ability gation into bee swarming on ships and where colonies are observed resting is needed. Alternatively, a ship may simply be a large object on which to to rest along the Adequate risk communication on bee swarming is im portant to reduce fear of bee sting exposures and pre vent unnecessary attempts to remove bees. Honey bee (or Hymenoptera in general) biology and avoidance countermeasures should be passed to ships crew before and periodically during contingency missions. Previous to disseminating this information during Continuing Promise 2015, the presence of the bees caused undue alarm as well as failed attempts to rid the area of bees, resulting in some reported bee stings where treatment was not sought. In some cases, the bee swarms went un noticed (increasing the risk for accidental exposure) by personnel transiting the affected areas. Using the name Africanized honey bee and not killer bee is preferable normal fear associated with the latter, often misleading description of honey bees in the SOUTHCOM AOR. Based on what is known about bee swarming biology, we do not recommend attempting to kill bees using in secticides for a variety of reasons, including safety of ships personnel as well as recent decline in bee populations worldwide. In most instances, bee swarms will move on within hours or a couple of days after arriving aboard a ship. It should be noted that honey bees, includ pollination services. Honey bees have also been trained to detect explosives and diseases such as cancer.22,23 The frequency and temporal trends of encountering large bee swarms during shipboard operations is not well documented, and lack of preventive countermeasures in advance may leave few options for bee removal and adequate risk communications to prevent sting expo sures. We hope that this information provides preven tive medicine/medical departments several options to prepare for such phenomenon during predeployment supply acquisitions, and provides a template to issue risk communications in the plan of the day or during other force health protection briefs for widest dissemination. Although swarming bees can be alarming to ships crew, sting exposures can be minimized with proper prepara tion and adequate avoidance measures. Our overarching goal is to improve risk communication on bee swarms and bee stings, and we encourage additional reporting of bee swarms aboard ships during future missions. ACKNOWLEDGE M ENTS We thank LTJG Elizabeth Gerardo for providing infor mation regarding recent technical assist visits conducted by Navy Environmental and Preventive Medicine Unit6 to control bee swarms, HMC Chris Guckeyson for

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36 http://www.cs.amedd.army.mil/amedd_journal.aspx providing information and corresponding image on bee swarm observations aboard USS Peleliu HM1 Robert Flores for information and corresponding image aboard USS Iwo Jima HM3 Jonathan Torres for assistance in gathering medical data, and Military Sealift Command civil mariners aboard USNS Comfort for reporting bee sightings. We also thank USNS Comfort Medical Treat Sears for supporting this work during Continuing Prom ise 2015, and LT Paula Volk and LTJG Christian Johnroe for reviewing and greatly improving earlier drafts of this manuscript. REFERENCES 1. Turbyville JC, Dunford JC, Nelson MR. Hymenop tera of Afghanistan and the central command area of operations: assessing the threat to deployed US service members with insect venom hypersensitiv ity. Allergy Asthma Proc 2013;34:179-184. 2. Army Regulation 40-501: Standards of Medical Fitness Washington, DC: US Department of the Army; 2007 (revised 2011):17. Available at: http:// Accessed November 21, 2015. 3. Command Policy Memo 07-307: Stinging Insect Policy. Fort Sam Houston, TX: US Army Medical Command; 2007. Available at: http://www.afpmb. 4. Manual of the Medical Department: NAVMED P-117 Washington, DC: US Department of the Navy; 2005 (update 2016). Available at: http:// www.med.navy.mil/directives/Pages/NAVMEDPMANMED.aspx. Accessed May 26, 2016. 5. Bureau of Medicine and Surgery Instruction 6150.35: Medical Warning Tag Washington, DC: US Department of the Navy; July 1991. Available at: http://www.med.navy.mil/directives/External Directives/6150.35.pdf. Accessed May 26, 2016. 6. Golden DBK. Insect sting anaphylaxis. Immunol and Allergy Clin North Am 2007;27:1-11. 7. Pankiw T. Reducing honey bee defensive responses and social wasp colonization with methyl anthrani late. J Med Entomol 2009;46:782-788. 8. Dunford JC, Turbyville JC, Leavengood JM Jr. Checklist of medically important Hymenoptera of Afghanistan. Insecta Mundi 2014;0339. Avail able at: http://digitalcommons.unl.edu/cgi/viewcon tent.cgi?article=1843&context=insectamundi. Ac cessed May 26, 2016. 9. Ferreira RS Jr, Almeida RA, Barraviera SR, Bar raviera B. Historical perspective and human consequences of Africanized bee stings in the Americas. J Toxicol Environ Health B Crit Rev 2012;15(2):97-108. 10. Armed Forces Pest Management Board. Techni cal Guide 34: Bee Resource Manual with empha sis on the Africanized Honey Bee Silver Spring, MD: Armed Forces Pest Management Board; 2013. Available at: http://www.acq.osd.mil/eie/afpmb/ docs/techguides/tg34.pdf. Accessed May 26, 2016. 11. Occupational Safety and Health Administration. Africanized Honey Bee [internet]. 2014. Available at: http://www.oshasafetymanuals.com/african ized-honey-bee/. Accessed November 21, 2015. 12. Seeley TD, Visscher K, Passino KM. Group de cision making in honey bee swarms. Am Sci 2006;94:220-229. 13. DeBerry S, Crowley J, Ellis JD. Swarm control for managed bee hives [internet]. Gainesville, FL: Uni versity of Florida Institute of Food and Agricultural Sciences; 2012;ENY-160. Available at: http://www. 14. US Department of Agriculture. Africanized Honey Bees [internet]. 2011. Available at: http://www.ars. usda.gov/Research/docs.htm?docid=11059&pf=1. Accessed November 21, 2015. 15. Betten DP, Richardson WH, Tong TC, Clark RF. Massive honey bee envenomation-induced rhabdomyolysis in an adolescent. Pediatrics 2006;117(1):231-235. 16. Sherman RA. What physicians should know about Africanized honey bees. West J Med 1995;163:541-546. 17. Rajendiran C, Puvanalingam A, Thangam D, Ra gunanthanan S, Ramesh D, Venkatesan S, Sundar C. Stroke after multiple bee sting. J Assoc of Physi cians India 2012;60:122-124. 18. Reisman RE, Mller UR, Wypych JI, Lazell MI. Studies of coexisting honeybee and ves pid-venom sensitivity. J Allergy Clin Immunol 1984;73(2):246-252. 19. erate Hymenoptera sting challenge as a diagnos tic tool in highly selected venom-allergic patients. Ann Allergy Asthma Immunol 1995;75:30-32. 20. Gilbert S, Lewis LA, Schneider SS. The role of vi bration signal during nest-site selection by honey bee swarms. Ethology 2011;117(3):254-264. 21. Donahoe K, Lewis LA, Schneider SS. The role of vibration signal in the house-hunting process of honey bee ( Apis mellifera ) swarms. Behav Ecol So ciobiol 2003;54:593-600. 22. Los Alamos National Laboratory. Detecting ex plosives with honeybees: experts develop method Daily [internet] 2006. Available at: http://www. sciencedaily.com/releases/2006/11/061128140820. htm. Accessed November 21, 2015.HO N EY BEE SW ARMS A BO ARD T H E USNS COMFORT : RECOMM E N D A TIONS FOR STI N G P R EVE N TIO N SW ARM RE M OV A L, AN D MEDIC A L RE A DIN E SS O N MILIT AR Y S HIPS

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October December 2016 37 23. Halter R. Bees: mans best friend, provider and protector [internet]. The Telegraph November 2, 2010. Available at: http://www.telegraph.co.uk/news/science/8104213/Bees-mans-best-friend-provider-and-protector.html. Accessed November 21, 2015. AUTHORS LCDR Dunford is a USN medical entomologist who was deployed with the Directorate for Public Health, USNS Comfort during Continuing Promise 2015. He is currently assigned to the Navy and Marine Corps Public Health Center, Ports mouth, Virginia. CDR Kronmann is a USN infectious disease and internal medicine physician who was Director, Directorate for Public Health, USNS Comfort during Continuing Promise 2015. He is currently Associate Director for Public Health Services, Naval Medical Center, Portsmouth, Virginia. HM1 Peet is a USN preventive medicine technician who was deployed with the Directorate for Public Health, USNS Comfort during Continuing Promise 2015. He is currently assigned to Boone Clinic, Joint Expeditionary Base-Little Creek, Virginia. Air Station-Jacksonville, Florida.

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38 http://www.cs.amedd.army.mil/amedd_journal.aspxFungal diseases rarely cause death in healthy young people. Both obligate parasitic fungi and opportunistic pathogens cause these diseases. Some military person nel are infected in their work environment with fungal pathogens such as the agents of histoplasmosis and coccidioidomycosis. Certain fungal diseases pose an increased threat to military personnel and retirees be cause of the frequency of serious wounds, amputations, and organ transplants compared to the overall civilian population. The Department of Veterans Affairs treats veterans and retirees for wounds and diseases acquired while in service. There are ample reviews of historic disease trends in the US military; however, little comprehensive work has fo cused on all fungal deaths in the US Air Force (USAF).1 Previous reviews of zoonotic disease morbidity in the USAF did not consider fungal disease zoonotic,2 even if some derive from animal exposure. The US Air Force School of Aerospace Medicine maintains the Air Force Mortality Registry (AFMR). The AFMR is a unique resource that creates a database of all mortality data reserve, and retired USAF service members to track trends and patterns that are more precise than Depart ment of Defense casualty data. The AFMR tracks all causes of death including those from occupational and fungal diseases. We review those deaths in the context MA TERI A LS A ND METHODS We queried 442,856 AFMR death records for all deaths after December 31, 1969, to December 31, 2012. The AFMR uses the eases-10th Revision (ICD-10) codes to track causes of death. Death records were accessed when the ICD-10 code matched any of the following (or their subsections): aspergillosis, blastomycosis, candidiasis, coccidioido mycosis, cryptococcosis, histoplasmosis, mucormyco sis, pneumocystosis, sporotrichosis, zygomycosis, and verify place of death and other causes of death, if any. The death records included in this study were those of all individuals reported to have had a fungal disease as underlying cause of death. We used SAS 9.3 (SAS Insti tute Inc, Cary, NC) software for our analysis. RESULTS A ND CO MM ENT Overall, there were 216 deaths from fungal diseases from 1970-2012, summarized in the Table. There are limits to the data in the AFMR. Death records prior to the mid-1980s are sparsely represented and not all recent deaths have been documented, so records after 2010 could be underrepresented. Pathogenic and parasitic fungi are ubiquitous but rarely cause death in the developed world. They are often as sociated with travel, the elderly, or a compromised im mune system. Fatalities from fungal diseases are most often seen in the elderly as secondary infections, fol lowing organ transplants or chronic disease. Some fungi are legitimate parasites while others are only opportunistic environmental pathogens. We address each fun gal pathogen alphabetically instead of following phylo genetic order. Aspergillosis: Aspergillus spp are truly ubiquitous fungi with airborne conidia throughout the world.3 deaths related to these toxins. Aspergillus spp are sap rophytic fungi, but aspergillosis threatens patients who Mortality From Fungal Diseases in the US Air Force From 1970 to 2013 Richard K. Kugblenu, MPH Will K. Reeves, PhD, MS ABSTR A CT which tracks deaths for current and retired Air Force service members. We screened the records for all deaths caused by fungal diseases between 1970 and 2013. There were 216 deaths caused by a variety of diseases such as aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, histoplasmosis, mucormyco opportunistic candidiasis. Of the total 216 deaths, only 7 were active duty or active reserve personnel.

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October December 2016 39 are immunocompromised, and fatal cases of aspergillosis increased after the introduction of corticosteroids and immunosuppressant drugs.4 As pergillosis is currently the leading cause of fungal deaths in the United States.3 It was the second most com mon cause of death in the study, with in the AFMR was in 1989. Sixtyone percent (n=22) of aspergillosis deaths were recorded from 2000 to 2012, with 1 and 13 deaths recorded for the 1980s and 1990s, respectively. We have not found a record of a fe male death thus far. The deceased were retirees, 55 years and older, the majority of whom died of pulmonary infections. Blastomycosis: causes this relatively rare fun gal disease. Most cases in the United States were acquired in the eastern half of the country, with a rate of ap proximately 2 per 100,000 people.5This disease is relatively rare, with a low overall rate of mortality, but in some studies the death rate can exceed 12% in individuals over 65 years of age.5 In the USAF, there were 4 deaths, all of which were retired sites. Four deaths were recorded from 1999 to 2003, with one death per year, 2001 being an exception. There were no records of death from blastomycosis after 2003. Candidiasis: Numerous spp cause candidiasis, with being the most frequently report ed.6 Disseminated or invasive candidiasis is one of the most prominent fungal causes of mortality in the United States. While invasive candidiasis is rare in people with out risk factors, it is the fourth most common cause of hospital-acquired bloodstream infections in the United States.6 Patients often acquire candidiasis following a traumatic injury or organ transplantation, or after sup pression of the immune system due to age and/or other illness. Almost all of the 43 deaths (91%) recorded in the AFMR were men over the age of 60. While we are unable to know if they were suffering from underlying conditions, that is probable. A majority of cases (n=20 (46%)) were recorded from 2000-2012, preceded by 16 (37%) in the 1990s. Coccidioidomycosis: This disease is generally restricted to the western United States, where the causative agent is endem ic. It is an occupational hazard for military personnel training where soil is disrupted, such as on bomb ing ranges.7 Coccidioidomycosis contributed the third highest number of fungal deaths during our study period. Coccidioidomycosis was one of death for USAF retirees, with 32 deaths. There is no way of know ing if they acquired the infections while on active duty. It also caused 3 deaths of active duty airmen, with a death in 1970, 1972, and 1992. Of these, approximately 75% died in western states, and the other cases could have been acquired there and reported at the site of death. Almost half of the deaths (n=15 (46%)), were recorded in the 1990s. Cryptococcosis: Several cause cryptococcosis. Cryp causes disease and is most common in immunocompetent people.8 is associated with animals and Cryp is more associated with certain trees and contaminated habitats.8 Both pathogens cause cryptococcosis and are reported identically in death records. The pathogens are regionally focal. Fatal cases of cryptococcosis often in volve fungal meningitis.9 Cryptococcosis is one of the rate of 0.04% to 12% worldwide, and up to 70% mortal ity.9 The death of a 42-year-old male on active duty was recorded in 1985. All other cryptococcosis deaths were retirees. Ninety-one percent of the deceased were male, with one recorded as null. Most cases were reported in the 1990s (41.67%), which might be related to the ac Histoplasmosis: Histoplasmosis is a disease caused by It is a dimorphic soil fungus ( ) often associated with animal feces.10 The parasitic form of histoplasmosis usually invades the lungs. Histoplasmosis is known to be one of the more common, yet very serious, fungal diseases in older Americans.11 Histoplasmosis was considered Characteristics of individuals with fungal cause of death listed for the period 1970-2012 (N=216) in the US Air Force Mortal ity Registry.Variable n %N Gender Male 211 97.69Female4 1.85Unknown1 0.46Age Group20-44 years18 8.3345-54 years16 7.4155-69 years50 23.1565 years and older135 61.11Race White167 77.31Black32 14.81Hispanic4 1.85Unknown13 6.02Underlying Cause of Death Aspergillosis36 16.67Blastomycosis4 1.85Candida43 19.91Coccidioidomycosis32 14.81Cryptococcosis12 5.56Histoplasmosis12 5.56Mucormycosis/Zygomycosis7 3.24Pneumocystosis25 11.57Sporotrichosis2 0.93Unspecified mycosis43 19.91Duty Status Active Duty/Active Reserve8 3.70Retiree208 96.29

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40 http://www.cs.amedd.army.mil/amedd_journal.aspxamong the top 3 fungal diseases among Medicare re cipients, with the highest mortality.11Within our study period, we record 12 fatalities from histoplasmosis. Ninety-one percent of the fatalities were male. A 25-year-old woman serving as a USAF reservist was among the fatalities for histoplasmosis, as well as a 37-year-old active duty Airman. These deaths occurred in 1990 and 1991, respectively. The remaining 10 were male retirees aged from 62 to 89 years. The deaths oc curred from 1971 to 2007, with 3 deaths in 1993. Propor tionate mortality ratios for histoplasmosis as 1.2 from 1970-20101, indicating little to no difference between United States and Air Force proportionate mortalities. Hence, with the exception of the 2 individuals on active duty, the cases in retirees were predictable. Mucormycosis/Zygomycosis: These diseases are caused by myriad species of Mucomycetes. We com bined mucormycosis and zygomycosis deaths since they are both diseases caused by the same group of fungi. There are 7 records in the AFMR reporting mucormyco sis/zygomycosis as the underlying cause of death. This is the second most common fungal disease in immunocompromised patients, but some opportunistic spe cies infect immunocompetent hosts.12,13 Unlike many of the fungal disease where a single or limited number of pathogens are known, mucormycosis is caused by a wide range of pathogens and thus has a wide geographic reach. A 27-year-old male active duty member was re corded with mucormycosis/zygomycosis as underlying cause of death. Seventy-one percent of cases occurred in the 1980s. Pneumocystosis: Pneumocystosis is caused by Pneumo or a related spp.1 Pneumo was described as a protozoan in older literature.14 Pneumocystosis is rarely detected in healthy people, but up to approximately 70% of HIV-infected people have in their respiratory tract.15 Almost all of the cases of pneumocystosis are in individuals with AIDS or with long-term immunosuppression. Pneumo disease for two-thirds of AIDS patients in the United States during the onset of the AIDS pandemic.15 The PCP-related fatalities in the USAF are consistent with the trends for the AIDS pandemic. Approximately onemocystosis deaths in our study were reported in 1986, and there were 7 deaths total in that decade. There were 25 deaths in patients ranging in age from 35 to 80 years. The majority of deaths (n=13) occurred in the 1990s, with 5 deaths recorded since 2000. The most recently re corded pneumocystosis death in the AFMR was in 2012. Advances in antiretroviral drugs have greatly extended the lifespan and health of individuals infected with HIV. There were no female deaths recorded for pneumocys tosis. All subjects with this underlying cause of death in our review were retired. Sporotrichosis: This disease is caused by Sporothrix and most infections are opportunistic, selflimiting, and cutaneous.16 The primary route of infec tion is through cuts from fungus-contaminated wires, thorns, needles, etc. Among the fungal causes of death in the AFMR, sporotrichosis was the least common. Two deaths of retirees were recorded, with one dissemi of body organ/region affected. Both men were aged in their 60s. Additional information was not available, but presumably they had compromised immune systems. Unspecified Mycosis: candidiasis for the greatest number of deaths. While we do not have enough information on the deceased, a spe data, with 43 deaths. The death of a 52-year-old male ac the remainder were retirees. Two of the 4 women in our Based on the death records, the threat of fungal diseases to active duty Airmen is very low, and fatal cases are extremely rare. Women die less frequently from fungal infections, but are a smaller component of the military overall. ACKNOWLEDG M ENTS We thank James Escobar and the AFMR staff for their assistance with database access. The views expressed in this article are those of the authors and do not necessarily Department of Defense, or the US Government. Distri bution A: Approved for public release; distribution is un limited. Case Number: 88ABW-2014-5129, 5 Nov 2014. REFERENCES 1. Reeves WK, Bettano AL. A review of mortal ity from parasitic and vector-borne diseases in the US Air Force from 1970 to 2012. J Parasitol 2014;100(2):189-192. 2. Anna MM, Escobar JD, Chapman AS. Reported vectorborne and zoonotic diseases, U.S. Air Force, 2000-2011. MSMR 2012;61(10):11-12; discussion 12-14. 3. Latg JP. and aspergillosis. 1999;12(2):310-350.MORT A LITY FRO M F UN G A L DI S E AS E S IN THE US AIR FORCE FRO M 1970 TO 2013

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October December 2016 41 4. Lin SJ, Schranz J, Teutsch SM. Apergillosis casefatality rate: systematic review of the literature. 2001;32(3):358-366. 5. Centers for Disease Control and Prevention. Blas tomycosis--Wisconsin, 1986-1995. 1996;45(28):601-603. 6. Hughes WT. Systemic candidiasis: a study of 109 fatal cases. 1982;1(1):11-18. 7. Standaert SM, Schaffner W, Galgiani JN, et al. Coccidioidomycosis among visitors to a Coccidioi des immitis-endemic area: an outbreak in a military reserve unit. 1995;171(6):1672-1675. 8. MacDougall L, Kidd SE, Galanis E, et al. Spread of in British Columbia, Can 2007;13(1):42-50. 9. Park BJ, Wannemuehler KA, Marston BJ, et al. Estimation of the current global burden of crypto coccal meningitis among persons living with HIV/ AIDS. 2009;23(4):525-530. 10. Kwon-Chung KJ. Studies on I. Heterothallism and development of the ascocarp. 1973;65(1):109-121. 11. Baddley JW, Winthrop KL, Patkar NM, et al. Geo graphic distribution of endemic fungal infections among older persons, United States. 2011;17(9):1664-1669. 12. Etienne KA, Gillece J, Hilsabeck R, et al. Whole genome sequence typing to investigate the Apoph outbreak following a tornado in Joplin, Missouri. PloS One 2011;7(11):e49989. 13. Gomes MZR, Lewis RE, Kontoyiannis DP. Mur comycosis caused by unusual mucormycetes, nonRhizopus , and species. Clin 2011;24(2):411-45. 14. Feeney KT, Arthur IH, Whittle AJ, et al. Outbreak of sporotrichosis, Western Australia. 2007;13(8):1228-1231. 15. Morris SK, Brophy J, Richardson SE, et al. Blasto mycosis in Ontario, 1994-2003. 2006;12(2):274-279. 16. James TY, Kauff F, Schoch CL, et al. Reconstruct ing the early evolution of fungi using a six-gene phylogeny. Nature 2006;443(7113):818-822. AUTHORS When this article was written, Mr Kugblenu was an Oak Ridge Institute for Science and Education Fellow, Pub lic Health and Preventive Medicine Department, US Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, OH. He is now a Research Scientist 2 with the New York State Department of Health, Albany, NY. When this article was written, Dr Reeves was with the Public Health and Preventive Medicine Department, US Air Force School of Aerospace Medicine, Wright-Patter son Air Force Base, OH. Currently he is a Regulatory Analyst, Western Compliance Assurance Branch, Ani mal and Plant Health Inspection Service, US Department of Agriculture, Fort Collins, CO.

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42 http://www.cs.amedd.army.mil/amedd_journal.aspxBranches of the US armed forces provide public health support through preventive medicine services that re ed by infectious diseases of many types, including acute gastrointestinal (GI) illness outbreaks. Due to the nature of military operations and the requirement for sleeping, feeding and personal hygiene activities and facilities, service members are often at a high risk for rapid GI outbreaks.1 service members under them maintained themselves in a neat and clean manner and to stress to them the im portance of hygiene to their overall health and ability to serve. The importance of preventive medicine continued to be discussed in subsequent years. In 1818, Dr Joseph prior to his appointment, Dr Lovell communicated to other physicians the need for an emphasis on the inves tigation of the causes of disease and on the implementa ideas, of the causes of these diseases.2 2 To help combat the effects of disease on military pre typically considered medical professionals. This act ef to the creation of the Medical Service Corps. From this ing issues related to disease prevention.2 through enforcement of basic hygiene practices, food service sanitation and inspections, and vector control. after the Gulf War. To that end, preventive medicine Does Reducing Time to Identification of Infectious Agents Reduce Incidence Rates of Norovirus in a Population Deployed to Southwest Asia? Belle Federman, ScD CDR (Ret) David M. Claborn, MSC, USN ABSTR A CT

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October December 2016 43 medicine. With the implementation of the reengineer into one functional detachment type. With this reorga merged, providing more robust services (Table 1). level (Level I), individual service members and units are responsible for ensuring basic hygiene practices are have trained FST personnel trained by preventive medi corps level. These personnel are responsible for ensur ing support at Level I is adequate and functional. This operational capabilities are listed in Table 1. Most de ment has 12 personnel. The specialties include one environ is also responsible for shipping samples to laboratories are (1) the endemic disease section, (2) the occupational vices are not typically provided by a Level III medical is provided by preventive medicine units in the United States. Support is also provided by the proponent agen tissue, or other samples are collected and submitted to typical turnaround times ranging from 8 to 21 days. These delays lead to delays in implementation of con trol measures and may increase the incidence of cases. and subsequent reductions in the incidence of GI illness 983 rd MEDIC A L DET A CH M ENT (PM) DE P LOYED CAPA BILITIES AOC indicates area of concentration, MOS indicates military occupational specialty, both of which are medical skill designators. equipment for a military organization or unit. Table 1. Preventive Medicine Capabilities following the Army Medical Reengineering Initiative. Adapted from Army Regula tion 40-5 and Bosetti.3,4Medical Detachment, Preventive Medicine (Current) Mission Provide preventive medicine support and consultation in the areas of entomology, DNBI prevention, field sanitation, sanitary engineering and epidemiology to minimize the effects of vector borne diseases, en teric diseases, environmental injuries, and other health threats to deployed US forces and their allies. Basis of Allocation1 Detachment per 17,000 personnel. Assignment Assigned to a medical brigade or a medical group, and normally attached to an area support medical battalion or theater medi cal command. Mobility Unit is 100% mobile for all personnel and equipment in a single lift using its autho rized organic vehicles. Capabilities Provides surveillance and control of disease vectors and reservoirs in assigned areas, including area and aerial spraying. Collect ed samples are forwarded to the nearest Level IV or Level V facility.

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx viously mentioned, a typical detachment is comprised of deployed 2 environmental science and engineering of personnel, the equipment inventory preventive medicine equipment and laboratory equipment. The ad ditional equipment and personnel tic capabilities to the level typically at medical facilities in the United clear, chemical and biological de ous air pollutant onsite gas chro matograph mass spectrophotom radio-nucleotide monitors (FLIR lected from personnel presenting at the troop medical clinics. This data Surveillance and Response System on US military personnel. Laband shared electronically on the might be used in a broader mission, particularly monitoring for disease Table 2. Comparison of Standard and Enhanced Preventive Medicine Capabilities for the 983rd MED DET (PM).Standard MTOE Personnel (AOC/MOS)Enhanced MTOE(+) Personnel (AOC/MOS)Proposed MTOE Personnel(AOC/MOS)Environmental Science Officer (72D) Environmental Science Officer (72D) Environmental Science Officer (72D) Entomologist (72B) Environmental Science Officer (72D) Entomologist (72B) Detachment Sergeant (68S) Entomologist (72B) Microbiologist (71A) Preventive Medicine NCO (68S) Microbiologist (71A) Detachment Sergeant (68S) Preventive Medicine NCO (68S) Biochemist (71B) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine Physician (60C) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Detachment Sergeant (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Specialist (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S) Laboratory Technician (68K) Laboratory Technician (68K) Laboratory Technician (68K)MTOE modified table of organization and equipment AOC area of concentration MOS military occupational specialty Table 3. Initial Diagnostic Capabilities Using the JBAIDS and ABI 7500 Systems as of October 20, 2011.Target System Bacillus anthracis T1JBAIDS Bacillus anthracis T2JBAIDS Brucella JBAIDS Burkholderia JBAIDS Coxiella burnetii JBAIDS Eastern equine encephalitis virus JBAIDS Francisella tularensis JBAIDS Influenza virus A and B JBAIDS Influenza virus A SUBTYPING (H) JBAIDS Orthopox Viruses JBAIDS Rickettsia prowazekii JBAIDS Variola virus JBAIDS Venezuela equine encephalitis virus JBAIDS Western equine encephalitis virus JBAIDS Yersinia pestis T1JBAIDS Yersinia pestis T2JBAIDS Influenza virus A and B ABI 7500Influenza virus A SUBTYPING (H) ABI 7500Norovirus SEROGROUP 1ABI 7500Norovirus SEROGROUP 2ABI 7500 D OES R ED U CIN G T IME TO I DENTIF ICATION O F IN F ECTIO U S AG ENTS R ED U CE INCIDENCE R ATES O F N ORO V IR U S IN A P OP UL ATION DEP L O Y ED TO S O U T HW EST A SIA ?

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October December 2016 45 outbreaks, including gastroenteri ed funds to purchase primer sets to many of the more common infec tious agents related to gastrointesti Based on the normal protocol for preventive medicine services, a collect samples and send them to ample, if a suspected food borne environmental science and engi foodborne illness investigation. Because of the distance from these labs and the customs procedures for shipping biological samples, it released. Due to the length of this left guessing as to the controls and plemented to address the outbreak. typical turnaround time for a sam in the time needed to identify the and burden on the norovirus outbreak on service mem results and outcome of the usefulness of the enhanced MA TERI A LS A ND METHODS Daily, routine monitoring of reported disease nonbattle theatre level application that combines information from of responsibility. Data is reported by providers for indi vidual encounters through the Medical Communications for Combat Casualty Care computer system. The JMeWS is a theater integrates health related informa tion from all branches of the US and Marine Corps). Illnesses are ing monitoring of these systems, all encounters reported by the provider. During suspected GI outbreaks in system by the laboratory compooratory personnel at Landstuhl Regional Medical Center, Landstuhl, Germany. digital reporting systems, mem also monitored the use of over the provided for free from the phar ing the suspected GI outbreak, pharmacy technicians at totals from each location for similar medications, such to assess the similarity of the camp populations as de also performed to test for difference in daily incidence Table 4. Enhanced Diagnostic Capabilities Using the JBAIDS and ABI 7500 Systems as of April 20, 2012.Target System Bacillus anthracis T1JBAIDS Bacillus anthracis T2JBAIDS Brucella JBAIDS Burkholderia JBAIDS Coxiella burnetii JBAIDS Eastern equine encephalitis virus JBAIDS Francisella tularensis JBAIDS Influenza virus A and B JBAIDS Influenza virus A SUBTYPING (H) JBAIDS Orthopox Viruses JBAIDS Rickettsia prowazekii JBAIDS Variola virus JBAIDS Venezuela equine encephalitis virus JBAIDS Western equine encephalitis virus JBAIDS Yersinia pestis T1JBAIDS Yersinia pestis T2JBAIDS Influenza virus A and B ABI 7500Influenza virus A SUBTYPING (H) (DoD-GEIS Project)ABI 7500Norovirus SEROGROUP 1ABI 7500Norovirus SEROGROUP 2ABI 7500Salmonella enterica ABI 7500Giardia lamblia and G duodenalis ABI 7500Campylobacter jejuni ABI 7500 ABI 7500Yersenia enterolytica ABI 7500 ABI 7500Vibrio cholerae ABI 7500V parahaemolyticus ABI 7500 ABI 7500Legionella ABI 75001 subtyping ABI 75002 subtyping ABI 7500Influenza virus 2009 N1 subtyping ABI 7500

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx that camp location (and therefore access to rapid diag nostic testing) might have on outcomes. RESULTS Based on 2 ference in the makeup of camps by age since military populations tend to be more homogenous than civilian popula tions. From November 1st through No vember 9th, the number of reported cases increased from a normal base level of 1 During the documented outbreak in acute GI symptoms. Typical daily incidence rates for P During each outbreak, incidence rates increased rapidly P the reported outbreak, a sharp increase in the request P Camp Beuhring Camp Adder Camp ArifjanFigure 1. Map of generalized locations of US encampments of interest in Kuwait and Iraq, November 2011. Figure 2. Number of cases reporting to sick call with GI complaints for the period October 22, 2011, through November 21, 2011. The clinics are not open on Sundays, which caused an apparent decline in the number of personnel reporting for November 6 and November 13 camps (P <.001 pared to Camps Arifjan and Beuhring ( P <.003). 25 18 6 31 12 29 10 4 21 23 16 27 20 8 2 14 October 2011 November 2011 Camp Arifjan Camp Beuhring Camp Adder Date Reported G I Cases35 0 5 20 30 15 25 10 D OES R ED U CIN G T IME TO I DENTIF ICATION O F IN F ECTIO U S AG ENTS R ED U CE INCIDENCE R ATES O F N ORO V IR U S IN A P OP UL ATION DEP L O Y ED TO S O U T HW EST A SIA ?

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October December 2016 47 or food sample had to be shipped and ana of all cases of norovirus in Iraq could be attributed to the lack of rapid laboratory diagnostic services and subsequent delay in the implementation of controls (Table 5). CO MM ENT Norovirus is a nonenveloped, positive sense, acute gastroenteritis in humans. The virus is responsible for the GI outbreaks noted military settings have also been reported sels.5 The virus is highly contagious and The primary route is fecal-oral, either by person-toperson contact or through indi It can also duced via vomiting. The virus is relatively environment for several days. The average and general malaise.1 Symptoms can persist infectious through shedding of viral parti do not confer any lasting immunity. While often self-limiting, norovirus outbreaks can service members assigned to units mobi quickly became inadequate for the number of person Figure 4. Reported daily incidence per 1,000 service members aligned by peak than daily incidence at the other 2 camps ( P<.02). Daily Incidence Day of Outbreak 0 4 -5 -2 2 1 -3 5 -4 -1 3 7 0 1 4 6 3 5 2 Camp Arifjan Camp Beuhring Camp Adder Figure 3. Reported daily incidence per 1,000 service members for the period October 22, 2011, through November 21, 2011. Daily incidence at Camp Adder P<.02). Date October 2011 November 2011 Daily Incidence7 0 1 4 6 3 5 2 Camp Arifjan Camp Beuhring Camp Adder 25 18 6 31 12 29 22 10 4 23 16 27 20 8 2 14

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48 http://www.cs.amedd.army.mil/amedd_journal.aspxthe height of troop densities, most service members on living space. Concurrently, the ratio of latrines and hand operations. Because personnel to serve salads and fruit and cups on the drink serving line became ting the virus. The door handles sources for hand-to-mouth transmis sion of the disease. stool specimen. Because neither the troop medical clinic nor hospital labo ratories possessed diagnostic capabili ties for norovirus, any stool samples normally be sent to Landsthul Region al Medical Center (LRMC) in Germa ny for analysis. The typical turnaround ing all personnel entering any food establishment. If Figure 5. Number of requests for over-the-counter bottles of the antidiarrheal drug Loperamide given through the Camp Arifjan pharmacy. Results are tabulated weekly. Requests for Loperamide began to increase the week of October 8, approximately 3 weeks prior to documented increases in the number sick calls for acute GI complaints. P<.001). 1 Oct 19 Nov 12 Nov 5 Nov 29 Oct 22 Oct 3 Dec 15 Oct 8 Oct 26 Nov Number of Requests for OTC L operamide40 50 0 30 60 20 90 70 10 80 Day of Month (2011) Table 5. Distributions by age and sex are similar across all camps and to the overall curred among the 3 camps.Patient Age ( Years) Camp Arifjan (Kuwait) Camp Bheuring (Kuwait) Camp Adder (Iraq) Cumulative Army-wide 41.2% 42.7% 43.0% 42.3% 42.7% 26-30 23.0% 23.2% 22.7% 22.7% 23.0% 31-35 13.7% 14.6% 14.6% 14.6% 14.7% 36-40 10.3% 9.8% 10.5% 10.5% 10.6% 10.9% 9.7% 9.3% 9.9% 9.1% Patient Gender n=117 n=82 n=128 N=327 N=1,105,301Male 85.5% 84.1% 85.2% 85% 85.4% Female 14.5% 15.9% 14.8% 15% 14.6% Includes Active, Reserve, and National Guard components. D OES R ED U CIN G T IME TO I DENTIF ICATION O F IN F ECTIO U S AG ENTS R ED U CE INCIDENCE R ATES O F N ORO V IR U S IN A P OP UL ATION DEP L O Y ED TO S O U T HW EST A SIA ?

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October December 2016 49 service announcement on the outbreak and the need for sanitation of all bathroom surfaces. This sanitation oc no loss in mission capability. der, the number of affected personnel on any one camp in also affected a greater percentage of the total population. changes in protocols and en virus as a causative agent. Ultimately, laboratories are the cornerstone of disease diagnosis for public health. largely performed by clinical sults of these tests are needed by public health for surveil lance, outbreak investigations, and disease control. This is a core function of public health laboratories. This core func tion requires accurate and timely data. To improve the accuracy and timeliness of testing and reporting, clini menting the capabilities of the other. Historically, laboratory involved the use of clinical tests based on bacterial plating techniques or tests for reduce or limit the disease burden.8,9 set of symptoms and a public health response delay the recognition of an outbreak and an appropriate response. To effectively control disease outbreaks, it is critical that rapid detection occurs. Rapid detection of the causative curately and rapidly identify pathogenic organism not only by species, but also by the strain of the organism. Because the Table 6 causative agent for typical GI outbreaks. Civilian and military timelines are similar when using from weeks to hours. ative agent for typical G I outbreaks following sample collection by a civilian clinic or health department facility.a agent with laboratory capability embedded in deployed PM detachment. Process Days (cumulative) to completion of process after col lection of sample Process H ours Required Receipt of stool samples2 4Receipt of stool samples after col lection by provider1 2bResults of initial stool sample culture5 8Molecular subtyping4 6 (after receipt of sample) Case report to health department7 9Positive confirmation of causative agent 5 30 (cumulative follow ing sample collection, depending on time required for receipt) Isolate submission to public health laboratory8 10Interview12 for E coli 14 for Salmonella 18 for Campylobacter Molecular subtyping15 for E coli 18 for Salmonella 21 for CampylobacteraClosely comparable to the 8 21 days typically required when samples gathered in deployed loca tions must be shipped to an Area Medical Labora tory or Army Public Health Center laboratories in either Landstuhl, Germany, or Aberdeen Proving Ground, Maryland.bTime required if provider notifies PM of sample collection, and PM retrieves sample. Otherwise, it may require up to 24 hours for receipt.

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50 http://www.cs.amedd.army.mil/amedd_journal.aspxare able to produce results in as little as one hour, the cally reduced compared to classic laboratory diagnostic 9 only provide accurate, reliable, and quick diagnostics, to test foods for possible contamination.9 This could pro vide even more data for the investigation of foodborne disease outbreaks. Critical to our ability to respond to disease outbreaks is the rapid and continual develop foundation for the response by public health to emerging and infectious disease outbreaks. For infectious diseases, applying genomics and proteomics to the determination 11 into the preventive medicine mission. With this in mind, pabilities by nearly 5-fold and overall diagnostic capa ment, but has the potential to improve services provided in the deployed area of operations. ployed laboratories involved in disease monitoring and the advantage of portability and ambient reagent storage, on the other hand, is not easily portable and requires adapted for a very large number of applications. The success in controlling the norovirus outbreak, dem should consider permanent changes to the deployable propriate support equipment, reagents, and primer sets. This system has the potential to positively affect service diseases of military importance. REFERENCES 1. MSMR 2. The Evolution of Preventive Medicine in the Unit ed States Army, 1607-1939 [internet]. Washington, Bosetti T. Integrating Medical Surveillance into the Mission of the Medical Detachment (Preven tive Medicine) Army Regulation 40-5: Medical Services, Preven tive Medicine 5. gastroenteritis outbreaks in military forces. MSMR Heyman DL, ed. Control of Communicable Dis eases Manual lic Health Laboratory System. Public Health Rep 8. Syndromic surveillance and bioterrorism-related epidemics. Emerg Infect Dis 9. Microarray Detection and Characterization of Bacterial Foodborne Pathogens Int J Food Microbiol D OES R ED U CIN G T IME TO I DENTIF ICATION O F IN F ECTIO U S AG ENTS R ED U CE INCIDENCE R ATES O F N ORO V IR U S IN A P OP UL ATION DEP L O Y ED TO S O U T HW EST A SIA ?

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October December 2016 51 11. detection of Salmonella in food. Appl Environ Microbiol AUTHORS Diseases, Fort Detrick, Maryland. vironment, Topeka, Kansas.

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52 http://www.cs.amedd.army.mil/amedd_journal.aspxTraumatic brain injury (TBI) is an invisible injury of dom (OEF).1-8 Between 2000 and 2015, the Department US service members worldwide across all services and as mild. Common mechanisms of injury (MOI) for TBI in both OIF and OEF.10,11 Common deployment-relat common events that can result in a nonblast TBI include motor vehicle accidents, falls, assaults, rapid accelera es. Multiple studies have shown a pattern of sensory the presence of mTBI. 2 service connected disabilities, respectively, every Fis Tinnitus is estimated to have a and Operation New Dawn (OND). While the estimated 10 sured in most industrial occupational environments. craft, and tracked and wheeled vehicles, while common Hearing Loss and Tinnitus in Military Personnel with Deployment-Related Mild Traumatic Brain Injury ABSTR A CT related mTBI was completed. Chi-square tests and STS incidence rates were calculated to assess differences P P

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October December 2016 53 28 been shown to have an association with injury to the ear ment has been associated with acoustic trauma, per manent threshold shifts, tinnitus, tympanic membrane 28 that of service members who were not deployed and did from the detonation of IEDs in OIF and OEF have also underreported when such injuries occur in conjunction 10,11 to treat sustained illness or injuries within the deployed environment. compromise situational awareness and operational read iness. Soldiers have reported an immediate decrease sensorineural). there is reported evidence of TM perforation with use Tinnitus is a known symptom associated with mTBI, other non-head injuries. Oleksiak et al found a self-re 8 in the presence of a concomitant head injury. Lew et al 15 cause they: Identify risk factors that may further decrease hear Identify environmental factors that may increase nitus acquired from military service within the active risk factors associated with US service members and 10 ence was noted at audiometric octave frequencies 500 from US military personnel, reported that personnel

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54 http://www.cs.amedd.army.mil/amedd_journal.aspxwithout such head injury. The known association between deployment-related (ie, audiometric thresholds) and/or tinnitus in active duty or reservist service members is limited in scope. vice TBI ity The purpose METHODS Study PopulationThis study was an addendum to a study completed at py, and behavioral health). The study was approved by nel who: 1. 2. Were treated between January 2008 and February injury). Study cohort distribution of mechanism of injury. mTBI indicates mild traumatic brain injury; LRMC, Landstuhl Regional Medical Center. Blunt Force n(NB)=51 Rollover n(NB)=8 Bullet, Fragment, Other n(NB)=6 Sports, Recreation n(NB)=5 CoupContrecoup n(NB)=4 Motor Vehicle Accident n(NB)=32 Fall n(NB)=45 No Answer Given n(NB)=2 Nonblast Injury (NB)n=153 Improvised Explosive Device n(BE)=250 Rocket Propelled Grenade n(BE)=31 Mortar n(BE)=15 Grenade n(BE)=3 Other n(BE)=1 No Answer Given n(BE)=3 Blast-Exposed Injury (BE)n=303 mTBI Diagnosis And Seen at LRMC Eye ClinicN=500 No Audiometric Informationn=9 Combination Injuryn=35 H EARIN G LO SS AND T INNIT U S IN MILITAR Y P ERS O NNEL W ITH D EPL OY MENT -R ELATED M ILD TRA U MATIC B RAIN I NJU R Y

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October December 2016 55 by their primary care provider to the TBI Clinic. The di Measures deployed service member encountered a DoD audiolo 1. 2. 5. seded) of the Department of Army Pamphlet 40-501 as and clinical characteristics were also queried from ethnicity. Clinical characteristics that were obtained in noise sensitivity, total number of previous TBIs, and prescription or over-the-counter medication use. Details vice member was injured (OIF or OEF), and total num ber of previous deployments.Statistical Analysis cal record for each patient were collected, coded, and over-the-counter medications used by each patient and reported in the medical record were also captured in 2 test was performed to determine the independent samples t test was performed to determine study, these dates were used to calculate person-time The amount of person-time contributed by each patient For each patient, the number of elapsed days between all patients to obtain the total person-years at risk, which the incidence rate of STS per 1,000 person-years for each models were constructed for multivariate analysis, one

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56 http://www.cs.amedd.army.mil/amedd_journal.aspxwith STS as the dependent variable and the other with RESULTS Demographic and Clinical Characteristics vice, and enlisted personnel. Compared to nonblast served in the infantry, were dismounted at the time of injury, and had been deployed two or more times. No Table 2 shows the clinical characteristics of patients reported a previous TBI, a history of unprotected developed an STS between their reference and subse ( P Auditory Injury Outcomes blast patients, 88 (58%) had developed an STS. Because tion at each encounter captured in this study, the num total) had already developed an STS compared to their Table 1. Patient Demographic Characteristics by Blast Exposure Status.Characteristic Total (%N) N=456Blast (%n) n=304Nonblast (%n) n=152P value Age, year (meanSD)28.88.1 27.87.6 30.68.7 .001Sex<.001Male416 (91%) 298 (98%) 118 (78%)Female40 (9%) 6 (2%) 34 (22%)Race.14White312 (68%) 208 (68%) 104 (68%)Black71 (16%) 42 (14%) 29 (19%)Hispanic52 (11%) 41 (13%) 11 (7%)Other21 (5%) 13 (4%) 8 (5%)Service <.001Army378 (83%) 254 (84%) 124 (82%)Marine Corps44 (10%) 38 (12%) 6 (4%)Air Force23 (5%) 7 (2%) 16 (10%)Navy10 (2%) 5 (2%) 5 (3%)Civilian1 (<1%) 0 (0%) 1 (1%)Duty Status.12Active duty404 (89%) 274 (90%) 130 (86%)Reserve18 (4%) 8 (3%) 10 (6%)National Guard32 (7%) 21 (7%) 11 (7%)Other/Civilian *2 (<1%) 1 (<1%) 1 (1%)Military Rank.01E1-E6 377 (83%) 259 (85%) 118 (78%)E7-E9 42 (9%) 29 (10%) 13 (8%)Officer/Warrant Officer36 (8%) 16 (5%) 20 (13%)Civilian*1 (<1%) 0 (0%) 1 (1%)Military Occupational Specialty<.001Infantry173 (38%) 142 (47%) 31 (20%)Other/NR283 (62%) 162 (53%) 121 (80%)Mounted Status.001Mounted205 (45%) 121 (40%) 84 (55%)Dismounted242 (53%) 178 (58%) 64 (42%)Other/NR *9 (2%) 5 (2%) 4 (3%)Conflict at Time of Injury.19OIF273 (60%) 179 (59%) 94 (62%)OEF172 (38%) 123 (40%) 49 (32%)Other/Not Deployed *11 (2%) 2 (1%) 9 (6%)No. of Deployments.01 0 16 (4%) 9 (3%) 7 (5%) 1 139 (30%) 88 (29%) 51 (33%) 2 170 (37%) 105 (34%) 65 (43%) 3+131 (29%) 102 (34%) 29 (19%)NR indicates not recorded.*Not included in 2 analysis. H EARIN G LO SS AND T INNIT U S IN MILITAR Y P ERS O NNEL W ITH D EPL OY MENT -R ELATED M ILD TRA U MATIC B RAIN I NJU R Y

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October December 2016 57 per 1,000 person-years). selected patient characteristics showed that only infan op tinnitus when compared to their respective reference posure were 2.5 times more likely to develop tinnitus twice as likely to develop tinnitus than patients who did Table 2. Patient Clinical Characteristics by Blast Exposure Status.Characteristic Total (%N) N=456Blast (%n) n=304Nonblast (%n) n=152P value Previous Traumatic Brain Injury .04 Yes153 (34%) 112 (37%) 41 (27%)No303 (66%) 192 (63%) 111 (73%)History of Unprotected Noise Exposure<.001Yes159 (35%) 137 (45%) 22 (14%)No258 (57%) 137 (45%) 121 (80%)NR *39 (8%) 30 (10%) 9 (6%)Hearing Protection Device Issued<.001TCS183 (40%) 162 (53%) 21 (14%)Earplugs15 (3%) 13 (4%) 2 (1%)Headset12 (3%) 8 (3%) 4 (3%)Other4 (1%) 1 (<1%) 3 (2%)None82 (18%) 18 (6%) 64 (42%)NR*160 (35%) 102 (34%) 58 (38%)Significant Threshold Shift.06Yes 291 (64%) 203 (67%) 88 (58%)No165 (36%) 101 (33%) 64 (42%)Tinnitus<.001Yes242 (53%) 181 (59%) 61 (40%)No190 (42%) 106 (35%) 84 (55%)NR *24 (5%) 17 (6%) 7 (5%)Hyperacusis/Noise Sensitivity<.001Yes82 (18%) 69 (23%) 13 (8%)No362 (79%) 227 (75%) 135 (89%)NR *12 (3%) 8 (2%) 4 (3%)Nicotine Use.47Yes189 (41%) 129 (42%) 60 (39%)No257 (56%) 167 (55%) 90 (59%)NR *10 (2%) 8 (3%) 2 (1%)Posttraumatic Stress Disorder.46Yes323 (71%) 218 (72%) 105 (69%)No130 (28%) 83 (27%) 47 (31%)NR *3 (1%) 3 (1%) 0 (0%)Sleep Problems.78Yes384 (84%) 255 (84%) 129 (85%)No66 (14%) 45 (15%) 21 (14%)NR *6 (1%) 4 (1%) 2 (1%)Final Disposition.84Separation232 (51%) 153 (50%) 79 (52%)Return to Duty95 (21%) 61 (20%) 34 (22%)Rehabilitation81 (18%) 56 (18%) 25 (16%)Retired41 (9%) 29 (10%) 12 (8%)Other/NR *7 (1%) 5 (2%) 2 (1%)NR indicates not recorded. TCS indicates tactical communications system*Not included in 2 analysis.

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx CO MM ENT and clinical characteristics of personnel who were at vice, junior enlisted rank, infantry, dismounted status of P with tinnitus.Auditory Injury Outcome: STS blast mTBI patients, consistent with the previous stud ies. Over the surveyed career span (person-time at than nonblast mTBI patients. This differential incidence head injury. The difference in increased risk ratios be US service members who served in OIF and were both of the total population at the surveyed predeployment jury. This may be due in part to the fact that a reported vious reports have indicated that both deployment and It is likely possible that over half of the surveyed cohort may have had an STS (ie, patients. Therefore, these tests should be considered Blast injuries can result in acoustic trauma either in iso have previously been shown to be a risk factor for hear 15 The measured audiometric threshold tion of service members with di cant, that mTBI caused by blast Table 3. Incidence rates of STS per 1,000 person years by blast exposure status, postmTBI only, and age at time of mTBI.Diagnosed STS Blast (B) Nonblast (NB) Rate ratio (B/NB) n Total person-years at risk Rate per 1,000 person-years n Total person-years at risk Rate per 1,000 person-years All (N=291)203 1,757.5 115.5 88 948.1 92.8 1.24Post-mTBI Only126 1,340.5 94.0 50 659.5 75.8 1.24Age (years)18-22 64 268.1 238.7 12 70.8 169.4 1.41 23-26 51 291.2 175.2 21 119.2 176.2 0.99 27-33 49 488.5 100.3 26 300.0 86.7 1.16 34-59 39 695.6 56.1 29 458.1 63.3 0.89 H EARIN G LO SS AND T INNIT U S IN MILITAR Y P ERS O NNEL W ITH D EPL OY MENT -R ELATED M ILD TRA U MATIC B RAIN I NJU R Y

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October December 2016 59 an observed limitation of the current study as our analy duty US service members Auditory Injury Outcome: Tinnitus and Hyperacusis The overall prevalence of tinnitus in the current study Oleksiak et al.8 This discrepancy may be due to either a nosis of tinnitus in at least one ear by 50% compared more likely to have tinnitus postinjury than those pa tients who have nonblast TBIs. Similarly, those service deployment than those without a TBI. to have tinnitus than the 18 to 22 year old service mem P (tinnitus, TM perforation, etc). Yet another factor that revealed a reduced risk for de P al reported participants who report their race/ethnicity within civilian studies reveal an incidence rate for hy erans with tinnitus only. The current study revealed

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60 http://www.cs.amedd.army.mil/amedd_journal.aspxsis or noise sensitivity.Unprotected Noise Exposure/HPD Use inadequate to evaluate as a risk factor with respect to at the time of injury/acoustic trauma. Self-reported his and adjusted risk analyses in this study. Similarly, Wells devices can often be a barrier to these efforts which may tions. This may be due to a perceived diminished Other Factors and over-the-counter medications by study subjects to and/or tinnitus, especially those that are known to be associated with a two-fold increased risk of tinnitus. Most of these medications were used by too few patients This study Score. 51 there is over tion in the current study is consistent with literature in pared to those who never smoked. This supports our nosed with tinnitus in at least one ear. H EARIN G LO SS AND T INNIT U S IN MILITAR Y P ERS O NNEL W ITH D EPL OY MENT -R ELATED M ILD TRA U MATIC B RAIN I NJU R Y

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October December 2016 61 in time. CONCLUSIONS when combined with the fact that tinnitus and hear crease over time. Unlike other common militaryand/ tory system and may not be captured with a standard ACKNOWLEDG M ENTS This research was funded by the Military Operational We thank Mr Trevor Jerome for his assistance with We do not plan to inform participants of the publication of this study. REFERENCES 1. J Head Trauma Rehabil 2. Iraq. Am J Prev Med Semin Hear ror and their future impact on health care and Mil Med 5. ma. J Am Osteopath Assoc mild traumatic brain injury. NeuroRehabilitation Multisensory impairment reported by veterans with and without mild traumatic brain injury his tory. J Rehabil Res Dev 8. J Rehabil Res Dev TBI Worldwide Numbers since 2000 [internet]. 10. prevalence, risk factors, and outcomes in US ser vice members and veterans deployed to the Iraq and Epidemiol Rev 11. consequences and associated characteristics. Otol Neurotol 12. tibular dysfunction caused by blast injuries and traumatic brain injuries. Hear J of the Iraq War. Lancet

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx Laryngoscope 15. tory dysfunction in traumatic brain injury. J Rehabil Res Dev PLoS One ment: mild traumatic brain injury, blast, trauma, and Arch Phys Med Rehabil 18. Perspect Hear Hear Dis ord Res Res Diagn 20. 21. 22. 25. Noise. New Noise and Military Service: Implications for Hearing Loss and Tinnitus 28. Am J Audiol loss associated with US military combat deploy ment. Noise Health sociated with blast-related traumatic brain injury. J Rehabil Res Dev J Rehabil Res Dev US Army Med Dep J foration as a marker of concussive brain injury in Iraq. New Engl J Med U.S. combat veterans with mild traumatic brain in jury from Operation Iraqi Freedom. J Head Trau ma Rehabil Am J Prev Med Am J Audiol Cave KM, Cornish EM, Chandler DW. Blast Injury Terror. Mil Med Mil Med Army Pamphlet 40-501: Medical Services Hearing Conservation Program H EARIN G LO SS AND T INNIT U S IN MILITAR Y P ERS O NNEL W ITH D EPL OY MENT -R ELATED M ILD TRA U MATIC B RAIN I NJU R Y

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October December 2016 63 Modern Epi demiology Schairer K. Mild traumatic brain injury and as sociated effects on the auditory system. Perspect Hear Hear Disord Res Res Diagn injury and postdeployment tinnitus in active-duty Marines. J Head Trauma Rehabil adults. Am J Med Otol Neurotol and posttraumatic stress disorder. Am J Audiol tal disorders in the U.S. military. J Clin Epidemiol Aviat Space Environ Med ment in one device: for soldiers whose ears and lives depend upon it. Noise Health Mil Med 50. New Engl J Med 51. applications: report of the 2008 St. Louis workshop. J Neurotrauma 52. Nomura K, Nakao M, Morimoto T. Effect of smok analysis. Prev Med J Assoc Res Otolaryngol AUTHORS Dr Krishnamurti is with the Department of Communica

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx HISTORY OF GOOD LA BOR A TORY PR A CTICES New Zealand introduced good laboratory practice (GLP) standards in 1972 as the Testing Laboratory Registra tion Act, which addressed record keeping, animal han dling, dosing and observation procedures, equipment use, and facilities. Denmark passed a law the same year to promote GLPs. In 1975, Senator Edward Kennedy and representatives of the Food and Drug Administra tion (FDA) accused certain research laboratories in the United States of serious inadequacies in the execution and documentation of preclinical research studies. G. D. Searle and Company and Hazelton Laboratories were data storage, and poor test facility management; per forming inadequate personnel training; and committing fraud.1 However, a number of investigations were discovering serious problems before that regulatory mandate be came effective. The scope of the problem reached the of Industrial Bio-Test Laboratories (IBT) were indicted for providing false data to chemical companies, who in turn had presented that data to the US government to demonstrate their products were safe for market.2 The 200 pesticides, of which over 66% were judged invalid and only 19% acceptable. At that time, IBT operated the largest facility of its kind and performed more than onethird of all toxicology testing in the United States. In ad dition, IBT was accused of presenting results to chemical torials reported high rodent mortality and appalling hus bandry conditions that offended public sensitivities and confounded research results. The discoveries resulted in congressional hearings. The revelations led to reforms, cides in the United States and Canada. Three of the IBT 5 document entitled Good Laboratory Practice to the FDA and the Pharmaceutical Research and Manufac turers Association of America. Later that year, the FDA released proposed regulations on GLPs based on that Searle submission and published them in the Federal Register Final RuleCompliance Program Bioresearch Monitor ing: Good Laboratory Practices, which incorporated the requirement for a quality assurance (QA) department, Going GLP: Conducting Toxicology Studies in Compliance with Good Laboratory Practices LTC Erica Eggers Carroll, VC, USA ABSTR A CT Good laboratory practice standards are US federal regulations enacted as part of the Federal Insecticide, Fun health in the areas of pesticides, chemicals, and drug investigations in response to allegations of inaccurate data acquisition. Essentially, good laboratory practices (GLPs) are a system of management controls for nonclinical research studies involving animals to ensure the uniformity, consistency, reliability, reproducibility, quality, and integrity of data collected as part of chemical (including pharmaceuticals) tests, from in vitro through acute Bio-Test Laboratory scandal which led to congressional hearings and actions to prevent fraudulent data report ing and collection. Although the establishment of infrastructure for GLPs compliance is labor-intensive and time-consuming, achievement and maintenance of GLP compliance ensures the accuracy of the data collected from each study, which is critical for defending results, advancing science, and protecting human and animal health. This article describes how and why those in the US Army Medical Department responsible for protect ing the public health of US Army and other military personnel made the policy decision to have its toxicology challenges faced and how they were overcome are detailed.

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October December 2016 65 the requirement for protocol preparation (ie, a study plan), characterization of test and control materials, and the requirement to retain specimens and samples.1 Rob latory milestone: concept to legally enforceable code, designed to control and regulate the quality of laboratory-based operations.1The Environmental Protection Agency (EPA) encoun tered similar problems with data it received, and issued ducting studies relating to health effects, environmen tal effects, and chemical fate testing. Additionally, the Organization for Economic Cooperation and Develop ment (OECD) issued Principles of GLP in 1992, which disseminated information regarding the principles and their importance to many countries. Carson and Dent6 summarized the key events in the chronology of the implementation of GLP: 1972 New Zealand Testing Laboratory Registra tion Act 1972 Denmark National Testing Board Act 1976 US-FDA GLP Proposed Rule 1979 OECD Expert Group on GLP 1979 US-EPA GLP Proposed Rule, Toxic Sub stances Control Act (TSCA) cide, Fungicide and Rodenticide Act (FIFRA) research Monitoring: Good Laboratory Practices the FDA created 606 new positions to monitor biological research and began a pilot inspection program to deter included lack of QA departments, failure to test every batch of manufactured product, and failure to maintain standard operating procedures (SOPs).1In the year 2000, the FDA issued Toxicological Prin ciples for the Safety Assessment of Food Ingredients : Redbook 2000 ,7 with chapters on general guidelines for designing and conducting toxicity studies, includ ing GLP, test animals (and housing), test substances, experimental design, observations and clinical tests, necropsy, and microscopic examination. Currently, GLPs are also mandatory to ensure quality and integrity PUR P OSE OF GL PS To address and eliminate the concerns expressed in the 1970s regarding the credibility of toxicity testing, use of GLPs creates a clearly traceable audit trail from the data, to the initial report, and then to submission of each study, a quality assurance unit, adequate test sys tem and animal care facilities, well characterized test ar ticles, and suitably managed archives of specimens and records. The overarching purpose of GLP compliance, therefore, is safety and the protection of public health. THE INITI A TIVE FOR GL P CO MP LI A NCE IN THE AR M Y PUBLIC HE A LTH ORG A NIZ A TION In 1979, the FDA issued Guidance for Industry which established the requirement for GLP adherence for data generation to be used in an application for FDA approval. An initial GLP inspection was conducted of the Army the AEHA submitted a report of acute skin, eye and pho tochemical irritation to a DoD customer. Unbeknownst to the AEHA, the customer submitted that report to the FDA as part of a therapeutic substance approval request. One month later, the customer informed AEHA that the FDA had observed that the report format was inconsis tent with GLP regulations and then had decided to in spect AEHA facilities with regard to the conduct of that study. In November 1990, the FDA inspected and issued ing receipt and disbursal logs, characterization of the purity of test article, incomplete raw data, inadequate control animals, and more. The report included a task to describe corrective action taken and planned, including a timeline for completion. The AEHA acted immedi ecuted or planned. From that point forward, the AEHA senior leadership invested time and resources to become fully GLP-compliant, and issued policy mandating such from the Toxicology Division. The AHEA Chief of Staff in 1991 held quality science and quality deliverables among his highest priorities. In September of that year, he initiated a quality manage ment system for the AHEA Toxicology Division to take

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66 http://www.cs.amedd.army.mil/amedd_journal.aspxall measures necessary to establish the infrastructure to maintain compliance with GLP standards. This was deemed necessary because data from some studies per formed by the Division are submitted to the EPA as part of applications for product approval. The EPA and FDA only approve compounds whose safety data are gener ated under GLP-compliant conditions. As early as October 1991, principal investigators and other personnel attended GLP training and conducted an in-house gap analysis with special assistance by a organization, considering SOPs already in place, wheth er they were adequate, which new SOPs were needed, and what management controls were necessary to en sure compliance. Personnel from other divisions with an aptitude for quality assurance were reassigned into a na scent Quality Assurance Unit (QAU). In April 1992, the Toxicology Division was inspected by an outside con sultant for compliance with the EPA GLP under the FI FRA. Additionally, the consultant provided training for personnel. Those personnel, in turn, wrote policy mem oranda and drafted, evaluated, and established an inter nal audit program to perform regular self-assessments when appropriate. In the past, auditors had occasion ally spot-checked study conduct and compared methods used with approved animal use protocols, but such ex aminations were inadequate. With the new QAU, audits became much more stringent. Additional inspections in sure AEHA was maintaining course. The biggest challenge was to convince the staff of the value of the new requirements. Roughly 25% of the per sonnel recognized the need and supported it. Roughly 25% of personnel were unconvinced that the increase in administrative tasks would have any value in what they considered an already functional system of toxicity test ing, and roughly 50% of personnel reserved judgment until they could see for themselves whether it was worth the effort. It required a change in culture, which was facilitated by the mandate from senior leadership. SOPs, and the audit system. Credentialed GLP trainers annually trained Toxicology Division personnel. Ad ditionally, the QAU team sought additional training to augment their expertise with the standards to ensure that SOPs were adequately written and the laboratories under their purview were compliant. From the initial reassignment of duties in September 1991 to the present, the QAU has grown to 20 person nel who monitor the GLP compliance of todays Army Public Health Center (APHC)* Toxicology Directorate (TOX) and oversee quality control for the Laboratory Sciences Directorate, Radiation Safety, Animal Care staff, Human Protection, and the Institute Animal Care takes to successfully comply with GLP. Not every orga nization will need a multifunction QAU as is presently operating at the APHC. The mission will dictate the ex tent of quality assurance investment necessary. At APHC-TOX, we routinely use GLPs for toxicity test ing of all chemicals, whether or not they fall under the purview of the EPA. Provisions of the TSCA, FIFRA, and FDA regulations are met to produce data that can be submitted at a later date, if required. The last time EPA inspectors visited APHC was for a study of a mess kit cleaning compound, trichloromelamine, known of rats revealed oral toxicity of the substance when ingest ed. The organization was in full compliance with EPA requirements. Currently, GLP compliance is a way of life in the Toxicology Directorate. Training of SOPs is ongoing and formal GLP training is conducted annually, coordinated with another DoD facility that itself is mov ing toward compliance. PROS AND CONS OF GOING GL P The disadvantages of implementing GLP standards lead personnel (documented as such), adequate facilities cally tasked with ensuring compliance with all relevant sonnel, test articles or items must be adequately charac tion maintained. Equipment used during the course of a study must be shown to perform as required, may re quire calibration (and documentation of such calibration retained), and be adequately inspected, cleaned, and maintained, all with documentation. The SOPs must be drafted by subject matter experts, approved by manage ment (not QA), used to train personnel and to properly document preventive maintenance of test systems. Every *The Army Environmental Hygiene Agency was redesignated as the US Army Center for Health Promotion and Preventive Medicine (USA CHPPM) on August 2, 1994. On October 1, 2009, USACHPPM assumed additional responsibilites and was redesignated as the US Army Public Health Command, which was subsequently redesignated as the US Army Public Health Center on October 1, 2016.GOING GLP: CONDU CT ING TOXI C O L O G Y S T UDIE S IN COMPL IAN C E WI T H GOOD LABORA T ORY PRA CT I C E S

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October December 2016 67 content approved by the study director, and every study is concluded with a comprehensive study report with the work involved and the meticulous documentation documentation of achievements, well trained person more consistently produces a high-quality product. To document training of personnel on SOPs and to revise SOPs, the APHC QAU uses, and therefore TOX uses, a MasterControl software package (MasterControl, Inc, Salt Lake City, UT). It was selected because it not only tracks SOP revisions and training, but provides other capabilities as well, such as supply functions, accident/ injury reports, audit reports, and study protocols. The GLP regulations require documentation of any laboratory worksheets, records, memoranda, notes, or exact copies of such documents that result from origi nal observations and activities of a nonclinical labora tory study, and are necessary for the reconstruction and evaluation of the report of that study. Also required is an archive for orderly storage and expedient retrieval of all raw data, documentation, protocols/plans, and speci mens generated as the result of a nonclinical laboratory study. One exception is the pathologists working notes, including a working spreadsheet, are not considered raw data and are not subject to auditing. Only the signed, completed pathology reports (and processed tissues) are considered raw data subject to audit. This is because of the judgment involved in assigning severity scores to le sions, which frequently entails more than one viewing of ratory maintains properly functioning equipment, quali around the world, including developing countries, have demonstrated the capability to successfully perform GLP compliant studies. Some argue, however, these me ticulous practices are too painstaking in research that is not being submitted to a regulatory agency. Others claim that since studies that do not meet these standards good science may be performed without GLP compli ance. It is also accurate to state that compliance with GLP does not assure good science. Since good and bad science may be performed in GLP compliant or non compliant fashion, this argument misdirects the discus sion from the reason why GLPs are required: to ensure the accuracy of the data collected. Early discovery, animal model development, or other research in which the GLP model. Data and reports of nonclinical safety studies, however, are used to make public health deci sions; therefore, these studies must be meticulously con ducted and recorded to ensure transparency, that is, they can be reconstructed from the records to demonstrate the integrity of the data. The nature of the test article determines the regulating agency and, therefore, the ap plicable GLP regulations. The FDA is responsible for protecting and promoting public health through the reg ulation and supervision of food safety, tobacco products, over-the-counter pharmaceutical drugs (medications), vaccines, biopharmaceuticals, blood transfusions, medi cal devices, electromagnetic radiation emitting devices, cosmetics, animal foods and feed, and veterinary prod ucts. Under the TSCA, the EPA regulates all commercial chemicals and substances (such as lead, formaldehyde, asbestos, mercury, and polychlorinated biphenyls), and FIFRA requires it to regulate insecticides, fungicides, and rodenticides. As Robinson points out:GLP is not a luxury. It is a necessity for any professional laboratory wishing to gain and retain the respect of its employees, clients, [and] regulators.1 GL P CO MP LI A NCE A S A LIFESTYLE How does an organization know when GLP compliance has been achieved? Although internal audit processes the mark and recommend corrective action, it is ul timately the FDA or EPA inspectors who have the an swers for a given study. How is GLP compliance maintained? The organization continues to follow the SOPs and policies put in place to achieve GLP compliance, with continuous monitoring by QA personnel, and continuous training and process improvement. Each individual engaged in the conduct of or responsibility for the supervision of a study shall have the education, training, and experience necessary to perform the assigned functions.9 Thus, training is at the heart of GLP. It is important to note that in the United States, GLP compliance is ascertained per study. An organization in Europe. As illustrated in the Figure, good laboratory practices are comparable in the United States and other nations, but are not identical. ing a mission. Currently, the Division of Toxicologic Pa thology of the Toxicology Directorate, which performs statistical analysis on all data, transfers spreadsheets of histologic data to a biostatistician in another director ate who performs Fishers Exact test on the data using

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68 http://www.cs.amedd.army.mil/amedd_journal.aspx Conduct of a Study in Accordance with the Protocol58.130 (a) The nonclinical laboratory study shall be conducted in accordance with the protocol.792.130 (a) The study shall be conducted in accordance with the protocol. Section II 8.3.2. The study should be conducted in accordance with the study plan.Test System Conformity with the Protocol58.130 (b) The test systems shall be monitored in conformity with the protocol.792.130 (b) The test systems shall be monitored in conformity with the protocol.Labeling of Specimens58.130 test system, study, nature, and date of collection. This information shall be located on the specimen container or shall accompany the specimen in a manner that precludes error in the recording and storage of data.792.130 test system, study, nature, and date of collection. This information shall be located on the specimen container or shall accompany the specimen in a manner that precludes error in the recording and storage of data. Section II 8.3.1. to each study. All items concerning this Specimens from the study should be as appropriate for the specimen and study.Availability of Gross Findings to Pathologists58.103 a specimen from postmortem a pathologist when examining that specimen histopathologically.792.130 (d) In animal studies where histopathology is required, records when examining that specimen histopathologically.Manual Recording of Data58.130 (e) All data generated during the conduct of a nonclinical laboratory study, except those that are generated by automated data collection systems, shall be recorded directly, promptly, and legibly in ink. All data entries shall be dated on the date of entry and signed or initialed by the person entering the data.792.130 (e) All data generated during the conduct of a study, except those that are generated by automated data collection systems, shall be recorded directly, promptly, and legibly in ink. All data entries shall be dated on the day of entry and signed or initialed by the person entering the data. Section II 8.3.3. All data generated during the conduct of the study should be recorded directly, promptly, accurately, and data. These entries should be signed or initialled and dated.Changes to Mannually Recorded Data58.130 (e) Any change in entries shall be made so as not to obscure the original entry, shall indicate the reason for such change, and shall be dated and signed 792.130 (e) Any change in entries shall be made so as not to obscure the original entry, shall indicate the reason for such change, and shall be dated and signed Section II 8.3.4. Any change in the raw data should be entry, should indicate the reason for change and should be dated and signed the change.Automated Recording of Data58.130 (e) In automated data collection the time of data input.792.130 (e) In automated data collection the time of data input. Section II 8.3.5. Data generated as a direct computer responsible for direct data entries.Changes to Data Recorded by Automated Systems58.130 (e) Any change in automated data entries shall be made so as not to obscure the original entry, shall indicate the reason for change, shall be 792.130 (e) Any change in automated data entries shall be made so as not to obscure the original entry, shall indicate the reason for change, shall be Section II 8.3.5. Computerised system design should full audit trails to show all changes to the data without obscuring the original data. It should be possible to associate all changes to data with the for example, by use of timed and dated (electronic) signatures. Reason for Comparison of GLP Requirements for FDA, EPA and OECD. Adapted from FDA comparison chart.10 GOING GLP: CONDU CT ING TOXI C O L O G Y S T UDIE S IN COMPL IAN C E WI T H GOOD LABORA T ORY PRA CT I C E S

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October December 2016 69 statistical packages to deliver to the pathologist inci P values. The data going to the statistician and the tables returning from the statistician pass through the QAU auditor to ensure data integrity. The demands in labor and time on the production time of a large pathology report. Purchase of a pathology data management software package that is fully GLP-compliant meets the requirements for consis tency and transparency, and reduces the time required for statistical analysis of the histologic data. In 2015, an increase in the number and complexity of toxicity stud ies, new personnel, and new software capabilities on the market (eg, a standalone pathology module) drove a re examination of the feasibility of such a purchase. Mar ket research is being done thoroughly, inviting key local players who can ask the most important questions. Pur the toxicology mission. An organization that decides to go GLP may not need a policy statement. What may be essential, however, is steadfast leadership to change the corporate culture, codify the decision, prevent digression, and prioritize the investment of resources. Leadership should ensure reached, and leadership should embrace training, as sessment, data integrity, and commitment to continuous improvement as essential in providing useful products to ensure the health of the force and to maintain readiness. ACKNOWLEDGE M ENTS I thank Mr Michael P. Kefauver, Chemist and Qual ity Assurance Unit Auditor, and Mr Gene Sinar, Chief, APHC for their provision of historical documents for this manuscript as well as their editorial review. REFERENCES 1. Robinson K. GLPs and the importance of stan dard operating procedures. BioPharm Int [serial online]. August 1, 2003. Available at: http://www. biopharminternational.com/glps-and-importance2016. 2. Slade M, Hoffman E. Ideas & trends in summary; New York Times ideas-trends-in-summary-laboratory-official-ac cused-of-fudging.html?scp=216&sq=Deodorant&s 3. Editorial. The scandal in chemical testing. New York Times opinion/the-scandal-in-chemical-testing.html. Ac New York Times inreview/who-tests-the-product-testing-labs.html. 5. Schneider K. IBT-guilty: how many studies are no good? [internet]. National Resources Defense 6. Good Clinical, Labora tory and Manufacturing Practices: Techniques for the QA Professional Cambridge, UK: The Royal Society of Chemistry; 2007. 7. Food and Drug Administration. Redbook 2000: Guidance for Industry and Other Stakeholders-To sicological Principals for the Safety Assessment of Food Ingredients Washington, DC: US Food and Available at: http://www.fda.gov/downloads/Food/ GuidanceRegulation/UCM222779.pdf. Accessed Fouillet X, Geoly F, Long P. Society of Toxicologic Pathology position on histopathlology data collec tion and audit trail: compliance with 21 CFR Parts Toxicol Pathol 9. Morton D, Demp RK, Francke-Carroll S, et al. Best practices for reporting pathology interpretations with the GLP toxicology studies. Toxicol Pathol 10. Food and Drug Administration. Comparison Chart of FDA and EPA Good Laboratory Practice (GLP) Regulations and the OECD Principles of GLP Washington, DC: US Food and Drug Administra gov/downloads/ICECI/EnforcementActions/Bio AUTHOR LTC Carroll is Chief, Division of Toxicologic Pathology, Toxicology Directorate, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

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70 http://www.cs.amedd.army.mil/amedd_journal.aspxThe above scenario is an actual event experienced by author J. Topinka. Today, 4 years later, there is a lac tation room only several yards from where the junior ruary 2016, the Defense Health Headquarters (DHHQ) published (internal) information on DHHQ Lactation Support and the 3 lactation rooms that provide pri vate, clean spaces for nursing mothers and their babies. The rooms have a refrigerator for storing breast milk, a handwashing sink, pump cleaning supplies, comfort able chairs, and resource information. Volunteers have even provided blankets, pillows, white noise machines, privacy screens, resource materials, and other supplies. While there has obviously been a great deal of change in breastfeeding policy since March 2010 when the Patient Protection and Affordable Care Act (PPACA), Pub L No. 111-148 was signed into law, how does current policy and the law apply to female service members at a time when they are taking on more and more responsibilities and duties within the military? This article endeavors to answer that question and provide military and medical leaders, as well as clinicians, guidance on how to deal with the needs of nursing service members and address outstanding issues that will undoubtedly be debated in the future. THE FUND AM ENT A LS Constitutional Right?Even before state or federal laws supported breastfeed ing, courts throughout the country made an effort to pro tect nursing mothers. One federal case, Dike v School Board of Orange County Florida, Dike a kindergarten teacher, Janice Dike, breastfed her baby in a private, locked room at her school until the schools principal informed her that the practice violated a regulation. She tried to pump, but her baby refused the breast milk from a bottle. She then tried to get permission to breastfeed off the school campus but was refused. After the district court dismissed the case, she appealed to the 5th Circuit Court. While the Circuit Court held that her inter est in nurturing her child by breastfeeding is entitled in some circumstances to constitutional protection against state infringement, the aftermath of the decision did not go in Janice Dikes favor when the case went back to the trial court.State LawsPrior to 2010, there were, surprisingly, no federal laws that gave legal protection to mothers who wanted to breastfeed or pump for their babies. On the other hand, state laws on breastfeeding have existed in some form 1 Murtagh and Moulton provided a solid analysis of state laws on breastfeeding. While these state laws may not have had much effect on the rules and regulations of the military prior to 2010, they were in effect in cities and communi ties where service members lived and shopped, thereby According to Murtagh and Moulton,1 23 states and 2 ter ritories had enacted breastfeeding statutes by 2009 that, for the most part, focused on 3 main areas: break times, private locations, and workplace breastfeeding friend liness. Twenty-one of those state laws concentrated on An Expression of Change: Breastfeeding in the Military Joseph B. Topinka, JD, MHA, MBA, LLM Linda R. Turner, MLS Kim Lee, PhD, MSHP, PT MAJ Jodi Brown, AN, USA SCEN A RIO a US Army Baylor Graduate School professor that is near the main auditorium where her BOLC courses are being taught. She explains to the professor that she needs to express herself. The professor, open to an expression refers to the expression of breast milk. Second, she tells the professor there is no place available for her to express except the washroom, which is neither an appropriate nor healthy option. The professor

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October December 2016 71 breastfeeding break times, with 19 on private locations. Eight prohibited breastfeeding related discrimination in the workplace, and three encourage infant friendly or mother friendly workplaces. A current, very detailed list of state laws on breastfeed ing can be found on the National Council of State Leg islatures website (http:/ncsl.org). A review of this list shows that some states allow public breastfeeding. Un fortunately, many do not have any enforcement mecha nisms such as penalties for violating the rights of nursing indecent conduct. Unfortunately, in those states without such a provision, a nursing mother could theoretically be subject to prosecution. feeding, and that variance should at least be considered by members of the military who are assigned within those jurisdictions and who live in communities out side of a military reservation. While state breastfeeding military facilities, those facilities ultimately fall under federal control and the federal, jurisdictional authority Federal Laws (r) Reasonable break time for nursing mothers (1) An employer shall provide (a) a reasonable break time for an employee to express breast milk for her nursing child for 1 year after the childs birth each time such employee has need to express the milk; and (b) a place, other than a bathroom, that is shielded from view and free from intrusion from cowork ers and the public, which may be used by an em ployee to express breast milk. (2) An employer shall not be required to compensate an employee receiving reasonable break time under paragraph (1) for any work time spent for such purpose. (3) An employer that employs less than 50 employees shall not be subject to the requirements of this subsection, if such requirements would impose an employers business. (4) Nothing in this subsection shall preempt a State law that provides greater protections to employees than the protections provided for under this subsection. Murtagh and Moulton note in their article that the law will most likely promote better public health by im proving nursing mothers ability to express milk. Sec made breastfeeding an integral part of the nations minimal requirements of a private area to express breast milk and a reasonable break time to express breast milk that cannot be denied by anyone, anywhere, in any jurisdiction, state or federal. Technically, however, the law only applies to employees who are covered by the acts overtime provisions under 29 USC 213 (generally the last section of the law could yield discussions in the future should a state law be more protective of a nursing mothers rights. there is not much written on Pub L No. 108-109, Section According to the lan (January 23, 2004), provides that a woman may breast wise authorized to be present at the location. reservations. Like many of the state laws that have such provisions for public breastfeeding, however, this law does not have any enforcement provision. US MILIT A RY SERVICE POLICIES After the passage of the PPACA, author L. Turner wrote a small article regarding breastfeeding for the October 2010 issue of the US Army Medical Commands Mer cury.2 At the time, she and her associates believed that change for the military in terms of breastfeeding policy. While the section had public health in mind, it was really an instrument of labor law and therefore may not techni cally apply to the military. However, we believe it was

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72 http://www.cs.amedd.army.mil/amedd_journal.aspxan impetus to the policies that all the military services, including the US Coast Guard, have implemented. Paragraph 4.15 of Air Force Instruction 44-1023 ad dresses the use of a private, clean area for military ex ate. Supervisors are encouraged to work with a nursing mother to ensure her work schedule allows 15-30 min utes every 3-4 hours to pump breast milk. Section 15 of Marine Corps Order 5000.12E4 notes that, at a minimum, the servicewoman should be afforded the availability of a clean, secluded space (not a toilet space) with ready access to a water source for the purpose of pumping breast milk. Command involvement is essen tial, and supervisors and nursing mothers will collabo rate to keep to a minimum the amount of time required for milk expression. Section 106 of OPNAV Instruction 6000.1C5 stipulates availability of a private, clean room for expressing breast milk. There should be ready access to running water and refrigeration for safe storage of breast milk. The policy also addresses breastfeeding infants during duty hours on a case-by-case basis but granting such permis sion should not be a reason for granting excessive time for meals or from work. The Navy goes one step further through its Bureau of Medicine and Surgery Instruction 6000.14A6 which provides guidance for Navy Medical Department personnel at Navy military treatment fa cilities. This is an excellent resource for clinicians and administrators, especially those in a joint environment. US Coast Guard Command Instruction 1000.9 pro facility, storage, and lactation breaks. The policy is one The policy, as with the Navys, includes a case-by-case policy for requests for breastfeeding infants during duty hours. Army Directive 2015-4 38 describes the US Armys policy for a space with access to a safe water supply, may not be a restroom. No time requirement for pump to 30 minute breaks 2 to 3 times a day. Like the Navys General and the US Army Medical Command issued OTSG/MEDCOM Policy Memo 16-005 ,9 which provides comprehensive guidance to Army healthcare facilities great resource for medical leaders, especially those in a joint environment. The memo includes a sample work Breastfeeding Schedule Request, and a sample infant feeding policy standard operating procedure. MILIT A RY LE A DERSHI P A ND ORG A NIZ A TION A L CULTURE IMP LIC A TIONS The scenario presented at the beginning of this article includes examples of leadership at an individual level, but has more broad implications of leadership relative to the organizational culture of each of the branches of the ered her to commit not only to her family, but further commit to her branch of service and the public. He not only demonstrated individual leadership, but he distrib the needs of her family and to meet the needs of her duties. Others have demonstrated positive correlation between associate engagement and loyalty to the organi zation and between work place policies supporting work life balance.10,11 Leaders serving to support work life balance and empowerment increase associates engage ment and then subsequent loyalty to the organization. Another inference can be drawn from the perspective ally, mothers committed to the principle of breastfeed ing have equal commitment to their workplace roles and a commitment to leadership. A commitment to breast feeding parallels with high commitment to principled leadership. The professor further promoted the junior a role of promoted leadership makes an intentional deci sion and commitment to do what is best for her family by committing to breastfeeding in conjunction with the convenient. She makes the conscious choice to lead in this way. Her commitment to her family and the health of the baby can also be extrapolated to how she commits to those whom she serves in her executive leadership role. The professor in the scenario reinforced not only the supported one of the policy statements established by the American Academy of Pediatrics (AAP) on behalf of community leadership. The AAP has established a the infant and mother from breastfeeding. These health AN EXPR E SSION OF CH A NG E : BR EA STF EE DING IN TH E MILIT A RY

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October December 2016 73 ment include decreased absenteeism related to infant illnesses; improved physical recovery after childbirth; decreased risk of chronic diseases such as rheumatoid arthritis, cardiovascular disease, and cancer; and de creased risk of postpartum depression, imputing an year.12,13Contemporary leadership theories and best practices have originated from military leadership training and examples throughout history. The military branches have consistently modeled leadership in so many areas. 14 the Army of 2025 and beyond will leverage cross-cultural and regional ex same Vision statement, the Army states that:...it will consist of a balanced, versatile mix of scalable, expeditionary forces,composed of agile and innova tive institutions, solders, and civilians...with trusted pro fessionals who strengthen the enduring bonds between the Army and the people it serves.Versatility, balance, and innovation are all key concepts included in the Armys 2015 Vision of the Army in 2025 and beyond. 15 states that it will be a trusted and reliable joint partner with our sister services known Ray Mabus, US Secretary of the Navy, writes on behalf cludes changing the way that all personnel in the Navy think, challenging outdated assumptions, and removing bureaucratic processes that prevent great ideas from be coming reality.16 With these formal vision statements seemingly embracing the concepts of agility and in novation for balanced workforce of professionals, does the military not have the opportunity to support agility, balance, innovation, and leadership in workplace cul ture with such policies as breaks for breastfeeding? One must ask; are the practices of not supporting expression counter to the professed Vision of the military branches? Organizational culture is only as consistent and stable as the behavioral and policy practices throughout. UNFINISHED BUSINESS We believe that each branch of military service has made great strides in developing and implementing ser reasonable break time for a service member to express break milk and they require some place other than a bathroom that is shielded from view and free from in trusion by coworkers and the public. Some issues remain, however, which we think must feeding in public on federal property remains open for scribed earlier is, on its face, straightforward. But how does it apply on a military reservation where uniformity is key and professional appearance and good order and command had to withdraw a policy that required nurs ing mothers to nurse their infants discreetly and cover rescinded his breastfeeding policy that required nursing mothers to leave the area if they refused to use a private room or a nursing cover. The authors do not have a mag (4) presented earlier that addresses more prescriptive protections resulting from future state laws. What if a particular state affords a nursing mother more rights than are afforded to her on the local military installa tion? Will an exception to policy be implemented for the installation so that its policies can be consistent with the laws of the local communities? What if the nursing ser theticals are numerous, but they are worth discussing as an expression of change. CONCLUSION Hopefully, this article will educate many and stimulate debate among others. Change is inevitable, especially when public health is at stake; and the law is often the avenue through which change is made. As David Suzuki wrote:A baby nursing at a mothers breastis an undeniable The law and policy on breastfeeding will eventually catch up to nature, even in the military. With approxi mately 14% of the active-duty being women (15.3% of not only catch up to public health and policy recom mendations, but also has the duty to lead in workplace practices honoring the history and culture of leadership as demonstrated in the past.18,19

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx REFERENCES 1. Murtagh L, Moulton AD. Working mothers, breastfeeding, and the law. Am J Public Health nlm.nih.gov/pmc/articles/PMC3020209/. Accessed July 11, 2016. 2. Turner L. Laws give breastfeeding rights to moth ers nursing in public places. The Mercury [se rial online]. October 2010:8. Available at: http:// 12, 2016. 3. Air Force Instruction 44-102: Medical Care Man agement Washington, DC: US Department of static.e-publishing.af.mil/production/1/af_sg/pub 2016. 4. Marine Corps Order 5000.12E: Marine Corps Policy Concerning Pregnancy and Parenthood Washington, DC: Headquarters, US Marine Corps; December 8, 2004. Available at: http://www. marines.mil/Portals/59/Publications/MCO%20 5000.12E%20W%20CH%201-2.pdf. Accessed July 11, 2016. 5. OPNAV Instruction 6000.1C: Navy Guidelines Concerning Pregnancy and Parenthood Wash ington, DC: US Department of the Navy; July 14, instructions/OPNAV6000.1CPregnancyandParent hood.pdf. Accessed July 11, 2016. 6. Bureau of Medicine and Surgery Instruction 6000.14A: Support of Servicewomen in Lactation and Breastfeeding http://www.med.navy.mil/directives/ExternalDir ectives/6000.14A.pdf. Accessed July 11, 2016. US Coast Guard Command Instruction 1000.9: Pregnancy in the Coast Guard Washington, DC: US Department of Homeland Security; September 29, 2011. 8. Army Directive 2015-43: Revised Breastfeeding and Lactation Support Policy. Washington, DC: US Department of the Army; November 10, 2015. 9. OTSG/MEDCOM Policy Memo 16-005: Breast feeding and Lactation Support Policy Sam Houston, TX: US Army Medical Department; January 21, 2016. Available at: http://www.army. mil/standto/archive_2015-10-13/?s_cid=standto. Accessed July 11, 2016. 10. Angeletti MA. Workplace lactation program: a nursing friendly initiative. J Health Hum Serv Admin 2008,31(2):223-239. Available at: http://lib proxy.txstate.edu/login?url=http://search.proquest. untid=5683. Accessed July 12, 2016. 11. Swarnalatha C, Prasanna TS. Leveraging em ployee engagement for competitive advantage: strategic role of HR. Review of HRM 2013;2:139148. Available at: http://search.proquest.com/open origsite=gscholar. Accessed July 12, 2016. 12. American Academy of Pediatrics. Breastfeeding initiatives [internet]. Available at: https://www2. aap.org/breastfeeding/PolicyOnBreastfeeding. html. Accessed July 12, 2016. 13. Johnston M, Landers S, Noble L, Szucs K, Viehm ann L. Breastfeeding and the use of human milk. Pediatrics http://pediatrics.aappublications.org/content/129/3/ 14. US Army. The Army Vision: Strategic Advantage in a Complex World [internet]. Available at: http:// army.mil/e2/rv5_downloads/info/references/the_ army_vision.pdf Accessed July 12, 2016. 15. able at: http://www.af.mil/AboutUs.aspx. Accessed July 12, 2016. 16. Vision [internet]. 2015:pic2. Available at: http:// LoRes_3.pdf. Accessed July 12, 2016. inspiringquotes.us/quotes/bKR1_pSsQi3Dh. Ac cessed July 12, 2016. 18. CNN Staff. By the numbers: Women in the U.S. military. CNN US [serial online]. January 24, 2013. Available at: http://www.cnn.com/2013/01/24/us/ military-women-glance/ Accessed July 12, 2016. 19. of Active Duty U.S. Military [internet]. November 12, 2015. Available at: http://www.statisticbrain. com/demographics-of-active-duty-u-s-military/ Accessed July 12, 2016. AUTHORS Mr Topinka is an assistant professor in the School of Health Administration at Texas State University, San Marcos, TX, where he has taught courses in various top ics including employment and public health law. Ms Turner is a Health System Specialist with the Clinical Performance Assurance Directorate, US Army Medical Dr Lee is Graduate Programs Director and an assistant professor in the School of Health Administration at Tex as State University, San Marcos, TX, where she teaches courses in various areas including strategic management and supervisory management. Center, Aberdeen Proving Ground, MD.AN EXPR E SSION OF CH A NG E : BR EA STF EE DING IN TH E MILIT A RY

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October December 2016 75On October 14, 2014, The New York Times published the 1 1 The New York Times New York Times 2 Chemical Weapons Exposures in Iraq: Challenges of a Public Health Response a Decade Later ABSTR A CT The New York Times A US Army chemical warfare specialist examines potentially hazardous materiel discovered in an abandoned Iraqi chemi cal munitions factory, Camp Taji, Iraq, circa 2013. Photo cour tesy of SSG Ryan Jacobsma, US Army.

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx 2 New York Times 4 CLINIC A L EFFECTS OF MUST A RD C HE MIC A L W E A P ONS EX P OSU RE S IN IR AQ: C H A LLE NG E S OF A PUB LIC H E A L T H R E S P ONS E A DEC A DE LAT ER

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October December 2016 77 CLINIC A L EFFECTS OF SA RIN ELE M ENTS OF THE CW A INVESTIG A TION New York Times1 New York Times 1 11 AHLTA is the DoD electronic health record system.

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx 10,12 STRUCTURED INTERVIEW 11 CLINIC A L ASSESS M ENTS C HE MIC A L W E A P ONS EX P OSU RE S IN IR AQ: C H A LLE NG E S OF A PUB LIC H E A L T H R E S P ONS E A DEC A DE LAT ERThe chemical warfare agent exposure review processes for the respective service member and Veteran population cohorts. DOEHRS indicates Defense Occupational and Environmental Health Readiness System; STR, service treatment record; PH, Purple Heart. Medical Records Review DOEHRS & STR Structured Interview Medical Exam Examination Complete Risk Communication & Follow up Personnel File Review for PH Determination 1 Reported Cohort 2 Unit Cohort 3 PDHA/PDHRA Cohort Medical Records Review Possible No No Yes DOEHRS & STR Structured Interview Medical Exam Examination Complete Risk Communication & Follow up or Health or Well Being Concerns? Personnel File Review for PH Determination Evidence of Symptomatic Exposure? 4 Self Report Cohort Medical Records Review No DOEHRS & STR Structured Interview Medical Exam Examination Complete Risk Communication & Follow up Exposure or Health or Well Being Concerns Personnel File Review for PH Determination Evidence of Symptomatic Exposure?

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October December 2016 79 11 DOCU M ENTING THE INVESTIG A TION 12 10,12 RECOGNITION New York Times1 CO MM UNIC A TION: KEE P ING THE INDIVIDU A L A ND DOD LE A DERSHI P INFOR M ED CONDUCTING INTERVIEWS

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80 http://www.cs.amedd.army.mil/amedd_journal.aspx LONG-TER M FOLLOW-U P New York Times 1 The New York Times C HE MIC A L W E A P ONS EX P OSU RE S IN IR AQ: C H A LLE NG E S OF A PUB LIC H E A L T H R E S P ONS E A DEC A DE LAT ER

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October December 2016 81 FOLLOW-U P FOR MUST A RD EX P OSURES FOLLOW-U P OF NERVE AGENT EX P OSURE

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82 http://www.cs.amedd.army.mil/amedd_journal.aspx CONCLUSION C HE MIC A L W E A P ONS EX P OSU RE S IN IR AQ: C H A LLE NG E S OF A PUB LIC H E A L T H R E S P ONS E A DEC A DE LAT ER

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October December 2016 83 10 REFERENCES New York Times New York Times Department of Defense Manual 1328.33: Manual of Military Decorations and Awards: DoD-Wide Performance and Valor Awards; Foreign Awards; Military Awards to Foreign Personnel and U.S. Information Medical Aspects of Chemical and Biological Warfare Department of Defense Instruction 6055.05. Occu pational and Environmental Health (OEH)

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84 http://www.cs.amedd.army.mil/amedd_journal.aspx Neurotoxicology Mil Med Br J Ophthalmol Fundam Clin Pharmacol Inhal Toxicol J Neurol J Occup Health Ann Neurol US Army Med Dep J AUTHORS C HE MIC A L W E A P ONS EX P OSU RE S IN IR AQ: C H A LLE NG E S OF A PUB LIC H E A L T H R E S P ONS E A DEC A DE LAT ER

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October December 2016 85Waste-to-energy (WTE) offers a partial solution at the convergence of 2 major Department of Defense (DoD) concerns: (1) addressing health effects due to burn pit emissions exposures and (2) reducing dependency on fossil fuels in contingency environments. Operating forces, combatant commands, and technology develop ers are excited about the prospect of using WTE as a so lution, but a multitude of considerations and limitations must be integrated before it can be declared a success. reduced environmental impact, but ancillary advantages such as a reduction in health related concerns can only be inferred from minimally available information and to developing successful military equipment that can be employed in austere conditions where US forces are deployed. To date, industry has been very successful in developing large scale WTE systems intended to handle municipal solid waste from civilian urban areas. How ever, such commercially available systems are not de signed for harsh mobile deployment applications where burn pits have commonly been the expedient solution to solid waste disposal. The continuous presence of US forces in austere, deployed environments over the last decade has produced a growing concern over adverse health effects to service members from toxic burn pit emissions. These concerns have pushed alternate tech nologies, such as WTE, into the collective spotlight. When operating far distances from established instal lations, the DoD employs base camps which vary in physical size and personnel in order to accomplish vari ous missions. The exact base camp categories will be explained in more detail later, but generally the camps are categorized as extra small, small, medium, and large. Understanding the typical military waste streams at extra small and small base camps provides an awareness of the baseline of materials that require waste management treatment. This article synthesizes these components to create an understanding for the dynamic considerations that must be addressed to de cient, sustainable, and ultimately safer environment for US service members. Understanding the current state of knowledge for burn ards from burning waste must be addressed by a WTE system. Knowledge gaps from limited burn pit emission sampling data in deployed environments have been par tially addressed through simulated emissions testing. Presented in this article are the required DoD critical performance parameters and characteristics for a WTE system that is a safe alternative to burn pits. Within en vironmental considerations, this analysis is primarily as any material or substance [solid or liquid] that is in herently waste-like by being no longer suitable for its originally intended purpose1 In addition to narrowing the scope of environmental considerations to solid waste management practices, considerations will also be lim ited to bases with fewer than 2,000 personnel (of which extra small and small base camps are considered).2 HU MA N HE A LTH RISK FRO M OP EN-AIR BURN PITS Concern over the health effects of burning solid waste during deployments in combat theaters has been voiced by service members, veterans, the media, Congress, and the President. It has been the subject of several joint DoD and Veterans Administration (VA) symposia, scholarly articles, a military medical textbook, congressional in quiries, and federal legislation.3-9Waste disposal in contingency settings requires thought ful consideration of waste stream segregation, safe disposal of hazardous materials, personnel safety, and the available disposal infrastructure, in addition to the er disposal options. During Operations Iraqi Freedom Bridging the Gap Between Burn Pits and Waste-to-Energy Technology: Safe and Effective Waste Management in Contingency Operations Coleen P. Baird, MD, MPH Kawakahi Amina Capt Anthony D. Suh, USMC Lt Col Robert M. Eninger, USAF

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86 http://www.cs.amedd.army.mil/amedd_journal.aspx(OIF) and Enduring Freedom (OEF), there was a nota ble absence of supporting infrastructure or contracting combination of the two. At times, the sheer volume of waste required near continuous operation of burn pits at several locations, resulting in the constant produc tion of smoke. When conducting an open burn of solid waste, siting of the burn area is critical to ensure that it is downwind from living quarters and camp populations. Burn pit smoke plume direction is dependent on weather conditions, and smoke can linger low to the ground dur ing inversions.10 Consequently, considerations such as the direction of prevailing winds and location of person nel billeting areas had to be continually assessed as use of open burning persisted. As clearly illustrated in Figure 1, thick black smoke from open pit burning was often a visual cue accompanying odors, eye irritation, and/or cough. As the size and num ber of inhabitants increased at Joint Base Balad, Iraq, trash volume grew from 2 tons per day to several hun dred. While incinerators were purchased relatively early tual issues delayed their use, and in response, concerned preventive medicine personal conducted air sampling from January to April 2007. The sampling targeted ex pected burn pit emissions, including particulate mat ter (PM), volatile organics, metals, polycyclic aromatic hydrocarbons (PAH), and polychlorodibenzodioxins/ furans. The sampling was conducted over multiple 24hour periods at locations chosen to represent typical and maximum exposure levels for the general population. Additional sampling was conducted during different sea sons. From the 163 samples collected, 4,811 individual analyte results were obtained and used in a quantitative screening human health risk assessment. The cancer risk estimated in this assessment was in the range considered to be acceptable under US Environmental Protection Agency (EPA) guidelines, but some volatile organic com pounds were measured at levels that might be associated with acute irritation.10,11 Limitations of the environmen tal sampling and risk assessment methodology include incomplete capture of the variability in waste streams and meteorological conditions over time, and the poten 5Dramatic photographs of burn pit smoke and accounts of the exact nature of items (plastic water bottles, soiled military uniforms, tires, etc) which had been burned (indicating indiscriminant burning) circulated on so cial media and generated further concern. Congress re sponded with language included in the National Defense that were prohibited from uncontrolled burning, and limited the time period that a base commander could rely on open burning as the waste disposal method at base camps housing more than 100 personnel.12 In 2011, the Institute of Medicine (IOM) assessed air sampling data, risk assessment information, and relevant epidemi health risks associated with burn pit exposure.7 The IOM committee noted that monitoring data omitted some of the pollutants considered criteria pollutants in the United States such as sulfur dioxide, ozone, nitrogen di oxide, ozone, nitrogen dioxide, and carbon monoxide. They also stated that it was likely that additional pollut ants were present as the burning of household waste is known to emit other pollutants, but were simply not measured due to time or budget constraints. The IOM determined that health effects (particularly respiratory) from burn pit emissions exposures are plausible, due pri marily to PM, but that burn pits were likely only one of BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N S Figure 1. Smoke from open air burn pits, Joint Base Balad, Iraq, in 2006. Photo courtesy of CPT Scott Newkirk, USA.

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October December 2016 87 many sources contributing to ambient PM levels. The lit erature reviewed during the study provided limited but suggestive evidence of decreased pulmonary function (but not disease) associated with combustion products. Continued, active stakeholder engagement with Con into law on January 10, 2013.4 The law required the VA to establish a voluntary registry for veterans who had deployed to locations near open burn pits. The registry was subsequently expanded to include all deploymentrelated airborne hazards (to address hazard sources be yond burn pits) and named the database the Airborne Hazards and Open Burn Pit Registry (AHOBPR). In August 2013, DoD committed to include active duty ser vice members in the AHOBPR. Open burning of trash may be only one of many contributors to service mem risk fully under DoD control and thus unacceptable as a continued standard operating procedure. To date, over 59,000 service members and Veterans have enrolled in the AHOBPR registry, and the IOM is reviewing the in formation in order to determine how to best utilize the self-reported data. Respiratory conditions are the most plausible and most studied consequence of exposure to burn pit emissions. Geographically, personnel deployed to Southwest Asia are also exposed to other respiratory hazards, including onry, and local industry. The DoD conducted environ mental sampling to characterize these exposures, focus ing on ambient PM, a hazard which routinely exceeds health guidelines in the region.13,14 The studies evaluat ing associations between deployment and respiratory health indicate a range of different and occasionally a ) no evidence of an association between deployment and chronic respira tory conditions15,16; ( b respiratory diseases and deployment6,17,18; and ( c ) evi dence of increased respiratory symptoms but not a spe 19-22 Although these studies have methodological limitations that constrain the strength of the conclusions that can reasonably be drawn from them, Despite the interest in the health effects of burn pits, outcomes associated with them rather than those involv ing deployment as a variable. Newly reported chronic bronchitis or emphysema, newly reported asthma, and self-reported respiratory symptoms and possible burn pit exposure were examined among deployed Army and Air Force personnel surveyed in 2004-2006 and 20072008 (N=22,844). Increased symptom reporting was observed among Air Force personnel located within 2 generally support an elevated risk for respiratory out comes other than symptoms among personnel deployed within proximity of documented burn pits in Iraq.9 An other retrospective cohort study was conducted among military personnel who, between January 2005 and June 2007, were deployed to either of 2 locations with burn pits in Iraq, or to either of 2 locations without burn pits in Kuwait.6 Incidence rate ratios (IRRs) were estimated using 2 nondeployed reference groups. Rates among personnel deployed to burn pit locations were also com pared directly to those among personnel deployed to of encounters for respiratory symptoms (IRR=1.25; 95% CI: 1.20-1.30) and asthma (IRR = 1.54; 95% CI: 1.33-1.78) were observed among the formerly deployed personnel relative to personnel stationed in the United States. Personnel deployed to burn pit locations did not relative to personnel deployed to locations without burn pits. These results are consistent with the hypothesis that OIF deployment is associated with subsequent risk of re spiratory conditions. Elevated medical encounter rates were not uniquely associated with burn pits. The IOM review of data on the burn pit registrants may stimulate research into other potentially related health outcomes could be presumptively linked to burn pits by the VA. Whether associations with health conditions emerge or not, continued open burning of large volumes of trash is perceived to be dangerous to service mem with the host country, and are an unacceptable risk from a force protection standpoint. SI M UL A TING EM ISSIONS FRO M OP EN-AIR BURN PITS Operational burn pits, such as those used at large scales during OIF and OEF, no longer exist for study. There fore, simulating open air burn pit emissions is a critical effects. The challenge of simulated testing is twofold. First, the simulated waste must be reasonably represen tative of waste compositions observed across the range of waste characterization studies and waste input meth ods and composition should be uniform across various tests. Secondly, the emissions data collection methods should be uniform across tests, which allows for com parative analysis.

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88 http://www.cs.amedd.army.mil/amedd_journal.aspxIn 2012, two studies related to emissions from militarywaste sought to gain better understandings of open pit burning in an appreciably controlled environment. The emissions analyses of both studies were comprehensive and both efforts researched similar emissions constituents for various burn conditions. One study analyzed Facility (OBTF) to determine the effect on emissions when plastics were removed from the waste stream, namely plastic water bottles.23 The emissions analysis included: polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs), particulate matter (PM10, PM2.5), polychlorinated and polybrominated di oxins/furans (PCDD/F and PBDD/F), and criteria pol lutants. The study concluded that targeted removal of plastics (such as water bottles) has no apparent effect on reducing pollutants and may even result in increased production of PCDD/Fs and PBDD/Fs pollutants due to reduced British thermal unit (BTU) content of the waste resulting in lower overall combustion temperatures.23The second study compared emissions from 2 separate waste streams (municipal solid waste and US Army Depot waste) by way of 2 different disposal techniques (burn pits and an air curtain burner). The article studied, a comprehensive array of emissions including CO2, PM2.5, volatile organic compounds (VOCs), polyaro matic hydrocarbons (PAHs), polychlorinated dibenzo dioxins and -furans (PCDDs/PCDFs), polybrominated dibenzodioxins and -furans (PBDDs/PBDFs), and met als.24 The results suggested that emissions from the 2.5, VOCs, and PAH, and 50 times lower for PCDD/PCDF and PBDD/PBDF as compared to the open pit burning.24 While this study was very informative, both disposal methods employed actual municipal solid waste and garrison waste with unknown variations of composition and consistency. A standardized waste stream that sim for similar tests in the future. Moreover, a deliberately constructed and precisely controlled military waste standard would reduce uncertainty associated with var ied waste streams and allow for more accurate compari son between studies. OP EN BURNING EM ISSIONS OF INTEREST Common emissions of interests from burning waste can be drawn from the 2 studies mentioned above23,24 and generally include PM, VOCs, PAHs, and PCDDs/ PCDFs. However, to meet regulatory standards, a shorter bare-minimum emission testing list is available. Nonetheless, to meet academic research objectives, a BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N SFigure 2. Comprehensive emissions constituent list. Data from Woodall et al,23 Aurell et al,24 and EPA.25 Dioxins/Furans PXDD/PXDF PM2.5and PM10Carbon Monoxide (CO) Sulfur Dioxide (SO2) Nitrogen Oxides (NOX) (3/17) Metals Cadmium (Cd) Lead (Pb) Mercury (Hg) Opacity (1/5) Halogens Hydrogen Chloride (HCl) Volatile Organic Compounds (VOCs) Semi-Volatile Organic Compounds (SVOCs) Carbon Dioxide (CO2) Oxygen (O2) (16/21) PAHs (5/17) Metals Arsenic (As) Chromium (Cr) Copper (Cu) Iron (Fe) Nickel (Ni) (4/5) Halogens Total Hydrocarbons (THCs) Polychlorinated Biphenyls (PCBs) (5/21) PAHs Hexavalent Chromium Antimony (Sb) Barium (Ba) Beryllium (Be) Cobalt (Co) Manganese (Mn) Phosphorus (MP) Selenium (Se) Silver (Ag)Thallium (Ti) Zinc (Zn)

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October December 2016 89 much longer list of testing is possible. Several factors and regulations must be considered to determine what emissions are critically important for analysis. The size and function of a system for waste management applica tion at extra small and small base camps would classify the system as an other solid waste incineration (OSWI) unit under 40 CFR 6025 for systems built after 2004. pollutant concentration limitations for OSWI systems, presented in Figure 2. While relying on the regulations outlined in 40 CFR is appropriate for environmental regulations, it does little to inform researchers about the more than 180 emissions (http://www.epa.gov/haps/ini hazardous air pollutants and are toxic to human health. The US Army Research Laboratory provides an exten sive list of possible emissions that can be tested accord ing to EPA methods.26 Previous tests on simulated burn pit emissions that focused on health and environmental factors produced a list between the extremes of minimal requirements to comply with regulations and a compre hensive list that could be achieved with an unlimited budget (Figure 2). Emissions considerations must incorporate civilian reg ulations established by the EPA, such as the National Ambient Air Quality Standards (https://www.epa.gov/ criteria-air-pollutants/naaqs-table) and the Clean Air Act (42 USC 7401 et seq (1970)), for the system to be permitted for use in the guidelines established as Mili tary Exposure Guidelines.27 Additionally, the Overseas Environmental Baseline Guidance Document28 is appli cable for planning WTE use in a deployed contingency environment. The body of knowledge for emissions is vironmental concerns for individual and varied emis sions classes are available. Emissions analysis during WTE technology develop ment and assessment will generally be restricted due to limited money and/or time. Testing comprehensive ing a multitude of sampling trains, elaborate equipment sets, highly-specialized personnel, and considerable amounts of time. The extensive resources for sampling are required because there are no test methods, continuous emissions monitoring equipment, or direct reading instruments that can analyze all emissions concurrently. While some emissions such as CO2 at low costs with easily procured instruments, the vast majority of analytes of interest require ample time and money. Previous research has studied the feasibility of using emissions such as CO2 as surrogates to estimate other emissions constituents. However, surrogate testing may be only informative for exposure assessments in austere conditions and does not replace the need for a full suite of testing.29 It is important to note here that detailed emissions analysis is necessary for the DoD to fore, a prioritized list of emissions and standardized testing methodology must be established to maximize DOD ENERGY INITI A TIVES At the time of this writing, the DoD approaches the concepts of operational energy very differently than it has in the past. This shift is in part a result of current budgetary environments, but also the acknowledge a force multiplier if applied correctly. Lessons learned from OIF/OEF highlight that capabilities which reduce energy consumption, simplify logistics, and impart questionable value. To that end, there are several efforts within the DoD focused on aligning US military forces with future strategic goals, such as reductions in energy example, the Marine Corps Expeditionary Energy Of the mission to analyze, develop, and direct the Marine 30The Marine Corps Initial Capabilities Document for Ex peditionary Energy, Water and Waste31 (ICD) outlines 3 forms and systems, and (3) reduce the overall footprint in current and future expeditionary operations. The ICD formalized the need for analyzing waste as a step cy, and reduce resource requirements to handle waste. In the most illustrative example, waste disposal in aus tere environments using burn pits can require in excess of a pound of fuel for disposal of 2 pounds of nonhaz ardous solid waste. This new focus on waste, coupled with waste management as an integral part of environ mental considerations in base planning, has opened the waste disposal and energy production through WTE technologies. Waste-to-energy technology is not an entirely novel concept; commercial industry has honed the technology

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90 http://www.cs.amedd.army.mil/amedd_journal.aspxto marketable viability both domestically and interna tionally. In the private sector, the use of WTE technol ogy has been gaining momentum as a potential tool to transform solid waste into usable energy which supports efforts to manage waste in a closed loop fashion.32 How the miniaturization, containerization, and application of these systems into harsh austere environments that are new design challenges for the technology. Currently, waste handling in deployed environments can be ac complished several different ways; US forces manag ing disposal, contractor disposal, burying, contracting to third country nationals, incineration, burn pits, and burying, to name a few. However, in 2011, in response to concerns of exposure from burn pit emissions, DoD Instruction 5715.1933 established as policy:the prohibition of the disposal of covered waste in open-air burn pits during contingency operations, ex cept in circumstances in which no alternative disposal method is feasible.33(p1) FR AM ING THE PROBLE M FOR DOD SP ECIFIC WA STE-TOENERGY SYSTE M S burn pit use in deployed waste management plans, it 34,35 Compared to planning for US operations, or deployment into austere but permissive situations, deployed waste management at the far forward tactical edge faces challenges which are unique to these potentially hostile and expeditionary settings. Common operational environment consider ations include items such as geography, local economy, climate, and time. However, the threat of enemy hostili ties, which are continually adapting to exploit perceived entiates DoD applications from other austere WTE solutions such as island nations, remote rural communities, etc. In past operations, open-air burning of solid waste allowed deployed personnel to maintain focus on essen tial tactical tasks in the face of enemy threat. However, technological advancements have rendered rudimentary burning and similar methods far less advantageous. It is now necessary to choose a suitable alternative to burn pits that provides the same simplicity, convenience, and reliability without exposing service members to hazard ous air emissions. Guided by efforts to promote health and sustainability, the objective of waste management is to minimize the potential harm and cost of waste, which may be accom plished by developing options that are feasible, suitable, and sustainable.36(p1-2) To better understand the nature of the problem and how to develop alternative disposal options, limitations should also be considered.34 Waste disposal operations are strictly regulated by federal law in the United States for garrison and training. However, waste disposal policies mandated in the United States do not always extend into deployed environments due to constrained resources and shifted prioritiesforce protection often supersedes environmental protection in hostile environments. Expeditionary manpower, time, and resource limitations demand careful consideration. Expeditionary forces must conduct combat operations, in addition to day-to-day waste management, with only the manpower and resources organic to their unit. This and the respective attribute trade-offs. For example, contracting local nationals to conduct waste disposal is tary personnel to focus on tactical tasks, but it also ex poses personnel to the possibility of attack from within their contingency base. Similarly, although WTE sys tems have the potential to reduce energy consumption and volume of waste, they cannot do so at the cost of continual manning, excessive segregation/pretreatment of input waste, or extensive maintenance. Austere contingency base camps continually face enemy threats and pose particular challenges that presuppose installations often enjoy (eg, large waste feedstock sup addition, mere interservice differences in concepts of operations, tables of organization, tables of equipment, and budgets also impose limitations on joint courses of action. For example, naval shipping, where space is mensions and weights. Air Force lift capabilities face another strict set of shipping requirements related to container volume and weight. Army and Marine Corps units have different organic heavy equipment capabili ties, which also affect the physical design and transport ability of a candidate WTE system. Not surprisingly, these differences, among others, have driven the devel opment of widely varying WTE systems that military decision-makers may consider in disposal planning. Nonetheless, voids still exist in information relating to the deployed waste stream and WTE systems. Due to natural variability, there is still much uncertainty about deployed life-cycle disposal costs, waste composition, generation rates, and the available latent energy, despite the development of a standard deployed waste recipe. This uncertainty will be a source of risk in both acqui sition and planning. Based on a typical military waste stream feedstock, data should also be collected on net BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N S

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October December 2016 91 and air emissions. Therefore, standardized WTE test ment environment should be implemented to improve the deployability and effect on force protection of expe ditionary waste management. DE P LOYED WA STE MA N A GE M ENT PR A CTICES Waste management requires attention and resource dedication across the spectrum of military operations as a function of environmental considerations. Waste management must be deliberate whether the conditions are garrison and training activities, initial and mature combat operations, or peacetime operations such as foreign humanitarian aid or humanitarian assistance/ disaster relief scenarios. The joint Army/Marine Corps publication Environmental Considerations1 comprehen sure adherence to such considerations. Improper waste management has the potential to adversely affect force health protection through uncontrolled spreading of dis ease (disease vectors), exposure to hazardous materials, and exposure to hazardous waste. Understandably, doc trine guides commanders to place a lower priority on environmental considerations as necessitated by a threat analysis. However, if feasible, effective waste manage ment can reduce logistical burden, promote host-nation 36As discussed earlier, similar to the wideranging scope of environmental consid erations, military base sizes and planning factors have an extensive range as well. The joint Army/Marine Corps publication Base Camp2ence establishing and maintaining military 4 sizes by population as shown in Table 1. Smaller base camps tend to be more unique and mil camps tend to function in a manner similar to small cit ies, as they are hubs for personnel and logistics to sus tain forward extended forces. MILIT A RY SP ECIFIC WA STE CH A R A CTERIZ A TION A full understanding of base camp waste streams (com position and characteristics) is important to inform the research and development of WTE systems. Aside from percentage composition of various waste categories, the actual physical and chemical characteristics help deter mine WTE technology suitability and its effective de moisture content, chemical composition through an ul timate analysis, and energy content determination will encourage the best WTE system design. Each character istic affects how the WTE system will perform with the waste stream that it thermochemically treats (ie, com bustion). Moreover, waste streams also vary according to base camp size and mission set.* Through the Joint Deployable Waste to Energy (JD W2E) working group, DoD is considering WTE as a possible solution to its waste management problems. Most historical waste stream characterizations have been performed on medium and large (Table 1) base camp sizes. However, JDW2E has determined that de ployable containerized WTE implementation within the DoD will be at the extra small and small (Table 1) base camp sizes. Other than the waste analysis performed in the Philippines in conjunction with the bilateral 2015 Amphibious Landing Exercise-Philippines (PHIBLEX), only one other US military waste stream characteriza tion has been performed at smaller base camp sizes with the same methodology (Fort Hunter Liggett (FHL), California). The FHL study was performed on the 4th exercise.37The FHL and the PHIBLEX studies used the Ameri can Society of Testing and Materials (ASTM) D523192(2008)38 as the framework for their waste composi tion methodology. This is also a common standard used for other waste composition studies.39-42 Waste stream analysis has been affected by the characterization methodology used.43,44 Therefore, JDW2E has narrowed its focus on waste characterizations that adhere with this common methodology to aid in com parison studies. The JDW2E community is focused on contingency base camps for use of deployable WTE systems because contingency base camps have histori cally used open-air burn pits as a primary waste dis posal option. Although the PHIBLEX 2015 study was performed during an exercise, the waste stream closely resembled the contingency base camp environment due ranges, close-air support integration, logistics convoys) and the activities performed within the camp (eg, main tenance on vehicles, medical tents, billeting, mess tents was the only military waste stream study that has met all 3 requirements of a smaller base camp size, ASTM standard methodology, and contingency base camp fo cus. Additionally, to date it is the only military waste Table 1. Base Camp Clas 2Base Camp Population Extra Small50-299Small300-1,999Medium2,000-5,999Large *Internal, restricted access military document not accessible by the general public.

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92 http://www.cs.amedd.army.mil/amedd_journal.aspx theater, an area to which the United States has increased its focus of effort.45-47The waste composition study was con ducted on the waste stream produced by US Marines at the Crow Valley base camp.* The population at Crow Valley as small.2 The waste was predominantly composed of food (28.2%), cardboard (19.7%), and total plastics (15.3%). The waste stream revealed military and con tingency-types of waste due to the highly combat-simulated base camp environment and activity. Ammunition (5.56x45mm NATO), medical waste (used intravenous kit with needles), and hazardous waste (rags soaked with petroleum, oils, and lubricants) were found in the waste stream, despite prohibitions against such disposal. Figure 3 shows the composition of the PHIBLEX waste stream. Table 2 presents the 21 different waste categories that were assigned dur ing the PHIBLEX study. WA STE GROU P INGS A ND CO MPA RISON In an attempt to distill the salient points of the vari ous waste categories into an analysis with more utility geared for WTE technology, 4 waste groupings were created to standardize the waste compositions for objec tive comparison: total plastics, moisture, combustibles, and metals/inorganics/other. Statistical comparisons were made after combining the waste categories into these 4 groupings.* In a government report,26 the Army waste categories into 10 waste categories as the ASTM standard recommended.38 Their analysis compared various military waste compositions and created a standard waste recipe presented in Table 3. When these 10 categories are grouped again into the centage comparison suggests that the PHIBLEX 2015 waste is similar to the proposed standard waste recipe as shown in Table 4. However, detailed statistical analysis revealed that per centage composition did not suggest waste stream equivalency.* This was ric Wilcoxon/Kruskal-Wallis Rank Sums Test and the Dwass, Steel, Critchlow-Fligner Mul tiple Comparisons Test where P values were compared In-depth statistical comparison may suggest that there is a difference. Inherent food waste difference is acknowl edged between the 2 waste streams (actual vs repre sentative); for example, the Army Research Laboratory report26 used dog food as an easily obtainable, shelfstable surrogate to simulate the food waste observed in an actual base camp. Additionally, clean and new (vir gin) plastics were used instead of moisture-laden, soiled ENERGY FRO M WA STE: A POSSIBLE SOLUTION Waste characterization studies are the backbone of understanding mili tary waste and the data collected is essential for WTE technology devel opment. The studies form the basis of what materials and waste mixtures are used in simulated predetermined waste recipes, the starting point to test systems for DoD application, energy recovery potential, volume reduction, and health and environmental impact. As discussed earlier, emissions can waste in a controlled environment, where high temperatures can be maintained and smol dering conditions (which produce higher emissions) can BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N SFigure 3. Composition of waste stream for the Crow Valley base camp in the Philippines during PHIBLEX 2015. Note: all 7 plastics categories were consoli dated into one data component for this chart. Other, Organic Yard Waste Other, Inorganic Glass Rubber Textiles Hazardous Materials Metal, Ferrous Liquid Metal, Non-Ferrous Wood Paper, Mixed Plastics Cardboard, Corrugated Food Metal, nonferrous Food Plastics Paper, mixed Wood Other, organic Yard waste Other, inorganic Glass Rubber Textiles Metal, ferrous Liquid Hazardous Materials Cardboard, corrugated 20% 15% 14% 0.01% 0.07% 0.15% 0.4% 0.6% 1.1% 1.5% 2% 4% 7% 6% 28% 10% 15% 5% 0% 25% 20% 30% Percentage by Net Weight (mean) Table 3. Army Research Laboratory Proposed Waste Standard Recipe.26Categories Composition1Cardboard15% 2Mixed paper 10% 3Food Waste32% 4Total Plastics15% 5Wood14% 6Metals6% 7Glass1% 8Rubber & Neoprene1% 9Textiles3% 10Misc/Other3% *Internal, restricted access military document not accessible by the general public.

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October December 2016 93 be eliminated.24 Consequently, destruction of waste in a controlled and contained manner increases the pos sibility of harnessing usable energy from waste. There have been several technologies developed to handle municipal solid waste (MSW) in WTE systems, each preprocessing, power output, etc. Figure 4 outlines cur rently available processes to transform waste into ther mal energy and depicts the major steps involved for each Table 2. Waste Categories and Generation.Categories D escription Content Example Mean Composition [%] A verage D aily Generation [lbs]1Polyethylene Terephthalate (PET) Resin Code #1: Most common thermoplas tic polymer resin consists of polymerized units of the monomer ethylene terephthal ate, with chemical formula (C10H8O4)nWater bottles; beverage/food/ cleaner bottles2.5% 97.4 2High-Density Polyethylene (HDPE) Plastic Resin Code #2: A polyethylene ther moplastic made from petroleum Bottles, trash/cereal bags, sauce packets0.5% 20.3 3Polyvinyl Chlo ride (PVC) Plastic Resin Code #3:Third-most widely pro duced plastic, chemical formula (C2H3Cl)nFilm (cling wrap), construction materials0.4% 5.0 4Low-Density Polyethylene (LDPE) Plastic Resin Code #4:A thermoplastic made from the monomer ethylene MREs food bags/wrappings6.8% 321.2 5Polypropylene (PP) Plastic Resin Code #5: A thermoplastic poly mer with chemical formula (C3H6)nCereal containers, medicine bottles, straws 1.1% 67.2 6Polystyrene (PS) Plastic Resin Code #6: Synthetic aromatic polymer, chemical formula (C8H8)nStyrofoam, utensils, disposable food containers, MRE packaging2.0% 98.9 7Other Plastics Plastic Resin Code #7: Other Plastics not categorized/labeled with Code #1-6Reusable water bottles, UGR food trays2.0% 82.6 8Food Waste Discarded solid food leftovers/scraps origi nally intended for human consumption Field chow hall, UGRs, or MREs28.2% 1510.7 9Mixed paper Recyclable paper High-grade paper: office paper; paper trays14.3% 498.3 10Corrugated Cardboard Corrugated heavy-duty paper or paperbased fiberboard consisting of a fluted corrugated sheet and one or two flat linerboards. Boxes19.7% 1131.3 11Metals, Ferrous Alloys that contains a significant amount of iron. Ability to magnetize. Food-grade cans from UGRs; band ing Wire2.4% 98.9 12Metals, Nonferrous Alloys that do not contain a significant amount of iron. Does not magnetize. Aluminum cans, individual MRE packages5.5% 194.4 13Other Organics Combustible waste that does not fit in other waste categories Insects0.0% 0.1 14Other Inorganics Noncombustible waste that does not fit in other waste categories Concrete, asphalt, soil, stone, cigarette ash0.2% 6.0 15Wood All wood types from trees or woody plants Bamboo, construction wood (lumber), pallets6.9% 370.1 16Yard Waste Biodegradable waste which was once a plant (garden waste) Leaves, parts of bushes/vegetation0.1% 0.0 17Liquids Any fluid Liquids remaining in bottles4.0% 176.3 18Glass Transparent solid composed of SiO2Vehicle windshields, glass bottles0.4% 12.8 19Hazardous Waste Substance that poses a threat to human or environmental health Needles, medical waste with blood, MRE heater1.5% 59.3 20Textiles Cloth that was woven with fibers like thread or yarn Socks, uniforms, parachute cord, t-shirts1.1% 44.2 21Rubber Highly elastic solid substance (synthetic or natural) Tires, seals from ordnance packaging0.6% 26.0 100.0% 4820.7 Table 4. Comparison of Waste Groupings.4 Waste Groupings P HIB L EX 2015ARL Standard Waste R ecipe26Total Plastics15.3% 15%Moisture32.1% 32%Combustibles42.7% 43%Metals/Inorganics/Other9.9% 10%Total100% 100%

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94 http://www.cs.amedd.army.mil/amedd_journal.aspxmethod. Not unexpectedly, there are physical and ther mochemical limits to the current technology that rely on waste stream input volume and footprint requirement. With that in mind, there are only 4 physical processes that are practical to support processing of military-spe 49Direct combustion is a relatively simple process, as it requires minimal preprocessing of the waste feedstock. ash, absence of scrubbing systems to remove toxins from air emissions, and, qualitatively, negative public perception.49 Nonetheless, despite the lack of dedicated air emission handling systems, direct combustion sys tems usually provide better burn conditions, increased smoldering conditions, and cleaner emissions over con ventional burn pits. Direct combustion systems provide a technologically simple method for waste disposal by achieving volume reduction and relatively cleaner emissions. Another option is thermochemical processes that con vert waste into a secondary energy (liquid fuel) which sizes and are compatible with gas turbines and gas 50 ergy recovery, their designs become exceedingly com systems), the physical characteristics and quality of the fuel source become increasingly important. Munici pal solid waste is a heterogeneous fuel source. It var ies widely in moisture content, material size, and the composition is generally at the mercy of the supported community. Processes to transform waste to a more homogenous refuse derived fuel are available and have been investigated. Refuse derived fuel (RDF) can be generated from MSW by shredding, screening, sort ing, drying and/or pelletization in order to improve the handling characteristics and homogeneity of MSW.50 The Bosmans and Helsen50 review of WTE technolo gies focuses on RDF, due to the fact that systems such and processing waste is an additional design consider ation that adds complication to the waste disposal pro cess and must be carefully considered while designing a mobile and dependable solution for deployed forces in austere environments. BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N S Figure 4. Biomass energy sources. Adapted from Energie Aus Biomass49 with permission of its authors.

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October December 2016 95 System complexity is an extremely important consid eration. Generally, air emissions decrease as system rolysis). The tradeoff for better emissions is increased system intricacy and overall weight. Figure 5 illus trates the progression and tradeoff expectations for transitioning from burn pits to various WTE systems. Removing toxins from emissions is an important consideration for WTE systems and can be achieved by adding various cleanup technologies (known col lectively as air pollution control devices) to exhaust systems. Adding scrubbing systems to any WTE technology raises the complexity of a system and must be carefully considered for use in contingency environments where skilled maintenance support proach, WTE broadly promises volume reduction of waste in excess of 95% of original dimensions and re duced emissions as compared to open burn pits. Waste volume reduction is directly aligned with the strategy established by the DoD as outlined in the Strategic Sus tainability Performance Plan .51The goal is for the DoD to provide a safer alternative than burn pits to service members deployed in an aus tere environment and not hinder or unnecessarily bur den their mission, potentially turning what is currently a logistical burden into a potential energy resource. If a WTE system is developed for this purpose, testing and development protocols must align to simultaneously ad dress the health risk concerns, waste processing require (maintenance, durability in shipping, ability to operate in diverse environments, mobility, etc). The only way to conscientious service member input during all stages of system development. REFERENCES 1. Army Techniques Publication 3-34.5/Marine Corps Reference Publication 4-11B: Environmental Con siderations Washington, DC: US Department of the Army/Headquarters, US Marine Corps; 2015. Available at: http://armypubs.army.mil/doctrine/ DR_pubs/dr_a/pdf/atp3_34x5.pdf. Accessed May 5, 2016. 2. Army Techniques Publication 3-37.10/Marine Corps Reference Publication 3-17.7N: Base Camps Washington, DC: US Department of the Army/ Headquarters, US Marine Corps; 2013. Available at: [restricted access] https://armypubs.us.army. mil/doctrine/DR_pubs/dr_c/pdf/atp3_37x10.pdf. Accessed May 5, 2016. 3. another Agent Orange. Stars and Stripes August 4, 2009. Available at: http://www.stripes.com/news/ obama-says-burn-pits-won-t-become-anotheragent-orange-1.93801. Accessed February 24, 2016. 4. provements Act of 2012, Pub L No. 112-260 (2013). Available at: https://www.gpo.gov/fdsys/pkg/ PLAW-112publ260/html/PLAW-112publ260.htm. Accessed May 4, 2016. 5. Weese CB. Issues Related to Burn Pits in Deployed Settings. US Army Med Dep J April-June 2010:2228. Available at: http://www.cs.amedd.army.mil/ ameddjournal/2010aprjun.pdf. Accessed May 5, 2016. 6. Abraham JH, Eick-Cost A, Clark LL, et al. A ret rospective cohort study of military deployment and postdeployment medical encounters for re spiratory conditions. Mil Med 2014;179:540-546. doi:10.7205/MILMED-D-13-00443. 7. Institue of Medicine. Long-Term Health Conse quences of Exposure to Burn Pits in Iraq and Af ghanistan Washington, DC: The National Acad emies Press; 2011. Available at: https://iom.nation alacademies.org/Reports/2011/Long-Term-HealthConsequences-of-Exposure-to-Burn-Pits-in-Iraqand-Afghanistan.aspx. Accessed May 5, 2016. 8. Baird CP, Harkins DK, eds. Airborne Hazards Re lated to Deployment Fort Sam Houston, TX: Borden Institute; 2015. Available at: http://www.cs.amedd. army.mil/borden/Portlet.aspx?ID=87a2edd6da3e-4ed9-b0d2-8c1246e8f5f7. Accessed May 5, 2016. 9. Smith B, Wong CA, Boyko EJ, et al. The ef fects of exposure to documented open-air burn pits on respiratory health among deployers of the Millennium Cohort Study. J Occup En viron Med 2012;54(6):708-716. doi:10.1097/ JOM.0b013e31825107f9.Figure 5. Waste management system complexity vs emissions. Burn Pits Direct Combustion Gasification/Pyrolysis Plasma Treatment SIMPLE COMPLEXHigher Lower EMISSIONS Waste-to-Energy Technology

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96 http://www.cs.amedd.army.mil/amedd_journal.aspx10. Taylor G, Rush V, Deck A, Vietas J. Screening Health Risk Assessment Burn Pit Exposures, Balad Air Base, Iraq and Addendum Report Brooks City-Base, TX: Air Force Institute for Operational Health; 2008. Available at: http://www.dtic.mil/ cgi-bin/GetTRDoc?AD=ADA493142&Location= U2&doc=Get TRDoc.pdf. Accessed May 5, 2016. 11. Risk Assessment Guidance for Superfund. Volume I Human Health Evaluation Manual (Part A) Wash ington, DC: US Environmental Protection Agency; 1989. doi:EPA/540/1-89/002. Available at: http:// www.lm.doe.gov/cercla/documents/fernald_docs/ CAT/215579.pdf. doi:EPA/540/1-89/002. Accessed May 5, 2016. 12. National Defense Authorization Act for Fiscal Year 2010, Pub L No. 111-84 (2009). Available at: https:// www.gpo.gov/fdsys/pkg/PLAW-111publ84/pdf/ PLAW-111publ84.pdf. Accessed February 25, 2016. 13. Engelbrecht JP, McDonald EV, Gillies JA, Jay anty RKMJ, Casuccio G, Gertler AW. Char acterizing mineral dusts and other aerosols from the Middle East-Part 1: ambient sam pling. Inhal Toxicol 2009;21(4):297-326. doi:10.1080/08958370802464273. 14. Weese CB, Abraham JH. Potential health im plications associated with particulate mat ter exposure in deployed settings in south west Asia. Inhal Toxicol 2009;21(4):291-296. doi:10.1080/08958370802672891. 15. Abraham JH, Baird CP. A case-crossover study of ambient particulate matter and cardiovascular and respiratory medical encounters among US mili tary personnel deployed to southwest Asia. J Oc cup Environ Med 2012;54(6):733-739. doi:10.1097/ JOM.0b013e318253356c. 16. Epidemiological Studies of Health Outcomes among Troops Deployed to Burn Pit Sites Wash ington, DC: US Department of Defense; May 2010. Available at: http://fhp.osd.mil/pdfs/100604_FI NAL_Burn_Pit_Epi_Studies.pdf. Accessed May 5, 2016. 17. Szema AM, Peters MC, Weissinger KM, Ga gliano CA, Chen JJ. New-onset asthma among soldiers serving in Iraq and Afghanistan. Al lergy Asthma Proc 2010;31(5):67-71. doi:10.2500/ aap.2010.31.3383. 18. Barth SK, Dursa EK, Peterson MR, Schneider man A. Prevalence of respiratory diseases among veterans of Operation Enduring Freedom and Op eration Iraqi Freedom: results from the National Health Study for a New Generation of US Veter ans. Mil Med 2014;179(3):241-245. doi:10.7205/ MILMED-D-13-00338. 19. Roop SA, Niven AS, Calvin BE, Bader J, Zacher LL. The prevalence and impact of respiratory symptoms in asthmatics and nonasthmatics dur ing deployment. Mil Med 2007;172(12):1264-1269. doi:10.7205/MILMED.172.12.1264. 20. Smith B, Wong CA, Smith TC, Boyko EJ, Gack stetter GD. Newly reported respiratory symptoms and conditions among military personnel deployed to Iraq and Afghanistan: a prospective populationbased study. Am J Epidemiol 2009;170(11):14331442. doi:10.1093/aje/kwp287. 21. Szema AM, Salihi W, Savary K, Chen JJ. Respira tory symptoms necessitating spirometry among sol diers with Iraq/Afghanistan war lung injury. J Oc cup Environ Med 2011;53(9):961-965. doi:10.1097/ JOM.0b013e31822c9f05. 22. Abraham JH, DeBakey SF, Reid L, Zhou J, Baird CP. Does deployment to Iraq and Afghanistan affect respiratory health of US military person nel? J Occup Environ Med 2012;54(6):740-745. doi:10.1097/JOM.0b013e318252969a. 23. Woodall BD, Yamamoto DP, Gullett BK, Touati A. Emissions from small-scale burns of simulated deployed US military waste. Environ Sci Technol 2012;46(20):10997-11003. doi:10.1021/es3021556. 24. Aurell J, Gullett BK, Yamamoto D. Emissions from open burning of simulated military waste from forward operating bases. Environ Sci Technol 2012;46(20):11004-11012. doi:10.1021/es303131k. 25. Environmental Protection Agency. Standards of Performance for New Stationary Sources. 40 CFR Part 60. Available at: http://www.ecfr.gov/ cgi-bin/text-idx?tpl=/ecfrbrowse/Title40/40cfr60_ main_02.tpl. Accessed May 4, 2016. 26. Margolin JA, Marrone PA, Randel MA, All mon WR, Mclean RB, Bozoian PM. Test Stan dards for Contingency Base Waste-toEnergy Technologie s. Adelphi, MD: US Army Research Laboratory; August 2015:49-58. Report No. ARLTR-7394. Available at: http://www.dtic.mil/cgibin/GetTRDoc?Location=U2&doc=GetTRDoc. pdf&AD=ADA623363. Accessed May 4, 2016. 27. Technical Guide 230: Environmental Health Risk Assessment and Chemical Exposure Guidelines for Military Personnel Aberdeen Proving Ground, MD: US Army Public Health Command; 2013;C-1. Available at: https://phc.amedd.army.mil/PHC%20 Resource%20Library/TG230.pdf. Accessed May 4, 2016. 28. Overseas Environmental Baseline Guidance Document: DoD 4715.05-G Washington, DC: US Department of Defense; 2007. Available at: http:// www.dtic.mil/whs/directives/corres/pdf/471505g. pdf. Accessed May 4, 2016. 29. Schmidt MA. Health Risk Assessments of Waste Combustion Emissions Using Surrogate Analyte Models Ohio: Air Force Institute of Technology; 2013. Available at: http://www.dtic.mil/dtic/tr/fulltext/u2/ a582122.pdf. Accessed May 4, 2016.BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N S

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October December 2016 97 30. United States Marine Corps Expeditionary En ergy Strategy and Implementation Plan Washing ton, DC: Headquarters, US Marine Corps; 2011:5. Available at: http://www.hqmc.marines.mil/Por tals/160/Docs/USMC%20Expeditionary%20Ener gy%20Strategy%20%20Implementation%20Plan ning%20Guidance.pdf. Accessed May 4, 2016. 31. United States Marine Corps. Initial Capabilities Document for USMC Expeditionary, Energy, Wa ter, and Waste Quantico, VA: Marine Corps Com bat Development Command, Combat Development and Integration; 2011. Available at: http://www. hqmc.marines.mil/Portals/160/Docs/USMC%20 E2W2%20ICD.pdf. Accessed May 4, 2016. 32. Bosmans A, Vanderreydt I, Geysen D, Helsen L. The crucial role of waste-to-energy technolo review. J Clean Prod 2013;55:10-23. doi:10.1016/j. jclepro.2012.05.032. 33. Department of Defense Instruction 4715.19: Use of Open-Air Burn Pits in Contingency Operations Washington DC, US Department of Defense; 2011. Available at: http://www.dtic.mil/whs/directives/ corres/pdf/471519p.pdf. Accessed May 5, 2016. 34. Joint Publication 5-0: Joint Operation Planning Washington, DC: Joint Staff, US Department of Defense; August 11, 2011. Available at: http://www. dtic.mil/doctrine/new_pubs/jp5_0.pdf. Accessed May 5, 2016. 35. US Marine Corps. Publication 5-1: Marine Corps Planning Process Washington, DC: Headquarters, US Marine Corps; 2010. Available at: http://www.marines.mil/Por tals/59/MCWP%205-1.pdf. Accessed May 5, 2016. 36. Technical Manual 3-34.56/Marine Corps Interim Publication No. 4-11.01: Waste Management for Deployed Forces 2013. Washington DC: US De partment of the Army/ Headquarters, US Marine Corps; 2013. Available at: http://www.med.navy. mil/sites/nmcphc/Documents/oem/TM-WasteManagement-for-Deployed-Forces.pdf. Accessed May 5, 2016. 37. Rotty L. Solid Waste Characterization Study, Fort Hunter Liggett, CA Port Hueneme, CA: Naval Facilities Engineering Command, Engineering and Expeditionary Warfare Center; 2014. Report SSR-NAVFAC-EXWC-EV-1405. 38. ASTM D5231: Standard Test Method for Determi nation of the Composition of Unprocessed Munici pal Solid Waste. West Conshohocken, PA: ASTM International; 2008. doi:10.1520/D5231-92R08. 39. Aphale O, Thyberg KL, Tonjes DJ. Differences in waste generation, waste composition, and source separation across three waste districts in a New York suburb. Resour Conserv Recycl 2015;99:1928. doi:10.1016/j.resconrec.2015.03.008. 40. Al-Jarallah R, Aleisa E. A baseline study char acterizing the municipal solid waste in the State of Kuwait. Waste Manag 2014;34(5):952-960. doi:10.1016/j.wasman.2014.02.015. 41. Gidarakos E, Havas G, Ntzamilis P. Municipal sol id waste composition determination supporting the integrated solid waste management system in the island of Crete. Waste Manag 2006;26(6):668-679. doi:10.1016/j.wasman.2005.07.018. 42. Zeng Y, Trauth KM, Peyton RL, Banerji SK. Char acterization of solid waste disposed at Columbia Waste Manag Res 2005;23(1):62-71. doi:10.1177/0734242X05050995. 43. Beigl P, Lebersorger S, Salhofer S. Model ling municipal solid waste generation: a review. Waste Manag 2008;28(1):200-214. doi:10.1016/j. wasman.2006.12.011. 44. Edjabou ME, Jensen MB, Gtze R, et al. Munici pal solid waste composition: sampling methodol ogy, statistical analyses, and case study evalua tion. Waste Manag 2015;36:12-23. doi:10.1016/j. wasman.2014.11.009. 45. Panetta LE. The US Rebalance Towards the AsiaAvailable at: http://www.defense.gov/speech es/speech.aspx?speechid=1681. Accessed May 5, 2016. 46. Sustaining US Global Leadership: Priorities for 21st Century Defense Washington, DC: US De partment of Defense; January 2012. Available at: http://archive.defense.gov/news/Defense_Strate gic_Guidance.pdf. Accessed May 5, 2016. 47. A Cooperative Strategy for 21st Century Seapow er Washington, DC: US Department of the Navy; March 2015. Available at: http://www.navy.mil/lo cal/maritime/150227-CS21R-Final.pdf. Accessed May 5, 2016. 48. Kaltschmitt M, Hartmann H, Hofbauer H, eds. Energie Aus Biomasse 2nd ed. Berlin, Germany: Springer-Verlag GmbH; 2009. http://www.springer. com/us/book/9783540850946. Accessed February 25, 2016. 49. Amack DC. Waste-to-Energy Decision Support Method for Forward Deployed Forces thesis]. Wright-Patterson AFB, Ohio: Air Force Institute of Technology; 2014. Available at: http:// www.dtic.mil/dtic/tr/fulltext/u2/a599359.pdf. Ac cessed May 5, 2016 50. Bosmans A, Helsen L. Energy from waste: re view of thermochemical technologies for refuse derived fuel (RDF) treatment. Paper presented at: Third Annual Symposium on Energy from Bio mass and Waste; November 8-11, 2010; Venice, Italy. Available at: https://lirias.kuleuven.be/bit stream/123456789/276089/2/ABosmans2010.pdf. Accessed May 5, 2016.

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98 http://www.cs.amedd.army.mil/amedd_journal.aspx 51. DoD Strategic Sustainability Performance Plan FY 2014 Washington, DC: US Department of Defense; 2014. Available at: http://denix.osd.mil/sustainabil ity/upload/DoD-SSPP-FY14-FINAL-w_CCAR. pdf. Accessed May 9, 2016. AUTHORS ate students at the US Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio. Dr Baird is Chief, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland. Mr Amina is Senior Analyst, Global Defense, with the J81 Innovation and Experimentation Division, US Pa Lt Col Eninger is an Assistant Professor, US Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio.BRIDG IN G T H E GA P B ETWEEN BURN PI TS AND WA STE TO -EN ER G Y T EC HN O L OG Y: SAF E AND EFF ECT IV E WA STE MANA GEME N T IN C O N T IN GE N C Y O PE RA T I O N S US Marines observing smoke plumes from an open air burn pit in Afghanistan, September 2008 (DoD image).

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October December 2016 99 THE PERFOR MA NCE TRI A D A ND THE MILIT A RY FAM ILY 1 2 2 Army Times 1 3 4 5 6,7 MILIT A RY PETS: FOURLEGGED FAM ILY 810 11 HE A LTH BENEFITS A ND THE HU MA N ANI MA L BOND: A REVIEW Animal-Assisted Health and the Performance Triad

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100 http://www.cs.amedd.army.mil/amedd_journal.aspx 12 13 14 15-17 In 18 20-22 23 24 25 26 27 28 23 30 31 23,32,33 34,35 36-38 35 40 41ANIM AL-ASSIS T ED HE AL TH AND TH E PERFORM ANCE TRI A D

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October December 2016 101 ANI MA L-ASSISTED HE A LTH A ND THE TRI A D: FOR M ING ACTION A BLE GO A LS 42 Engage in Activity: Animal-Assisted Health 43 44 45 14,46-48 24,47 Figure 1. Army Medicine fully supports integrating family pets into the Triad. This poster depicts an owner engaged in pur poseful activity with her dog Bella. Poster courtesy of the US Army Public Health Center.

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102 http://www.cs.amedd.army.mil/amedd_journal.aspx Improve Nutrition: Animal-Assisted Health 50 51 52 53,54 55 56 57 ANIM AL-ASSIS T ED HE AL TH AND TH E PERFORM ANCE TRI A D

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October December 2016 103 58 Dietary Guidelines for Americans 2015-2020 .60 61 Get Quality Sleep: Animal-Assisted Health 62 63 62 64 65 66 67 68 68 70 Figure 2. Army Medicine fully supports integrating family pets into the Triad. This poster depicts an owner engaging in mu her dog Gracie. Poster courtesy of the US Army Public Health Center. The Millennium Cohort Study is an ongoing longitudinal cohort study headquartered at the Naval Health Research Center in San Diego, California and designed to evaluate any long-term health effects of military service, including deployments. It is the largest populationbased prospective health project in US military history, currently collecting data on over 200,000 enrolled participants. Information available at: http://millenniumcohort.org/.

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104 http://www.cs.amedd.army.mil/amedd_journal.aspx 70 71 Sleep Review 71 67,68 72 73 CONCLUSION 74 75 76 77,78 REFERENCES Army Times Army Magazine ANIM AL-ASSIS T ED HE AL TH AND TH E PERFORM ANCE TRI A D Figure 3. Army Medicine fully supports integrating family pets into the Triad. This poster features Darwin to explain the of the US Army Public Health Center.

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October December 2016 105 2014 Demographics: Physi cal Activity Patterns and Satisfaction with Fitness Facilities Among Military Members and Their Families J Fam Psychol Pets and the Family Marriage Fam Rev Anthrozos Public Health Rep Hypertension Med J Aust J Nerv Ment Dis Psychosom Med J Al Allergy J Psychom Res Proc Natl Acad Sci U S A Stress

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106 http://www.cs.amedd.army.mil/amedd_journal.aspx Psychol Rep US Army Med Dep J Anthrozos Appl Anim Behav Sci Handbook on AnimalAssisted Therapy: Theoretical Foundations and Guidelines for Practice Science Br J Psychol Anthrozos Hand book on Animal-Assisted Therapy: Theoretical Foundations and Guidelines for Practice J Sports Sci Am J Prev Med Quest Med J Aust Am J Public Health Prev Med Obesity (Silver Spring) Obesity (Silver Spring) JAMA J Am Vet Med Assoc ANIM AL-ASSIS T ED HE AL TH AND TH E PERFORM ANCE TRI A D

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October December 2016 107 Obesity (Silver Spring) Guidance for J Am Anim Hosp Assoc Di etary Guidelines for Americans 2015-2020 Health Behaviors of Adults: United States, 2005-2007 Sleep Disord Sleep Sleep Sleep Rev Sleep Med Rev The Perceptions of Animals in Annu Rev Public Health Anthrozos Anthrozos AUTHOR

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108 http://www.cs.amedd.army.mil/amedd_journal.aspxReal life scenarios? Yes. Two of the authors experienced these situations and, at the time, really did not have an swers to the questions that were being asked: Was the inpatients dog a service animal? Did the school have to accept the childs service animal in the classroom? If so, what were the patients rights, and what were the facili ties rights and duties under the law? Does the Americans with Disabilities Act (ADA) (42 USC chptr 126) control these scenarios, or can local policy supersede federal and state laws? Was the little dog in the basket a therapy or activity animal, or simply a companion, social animal, or a pet? Depending on its status, what legal restrictions or options were available to the administrative staff at these facilities? These questions are certainly not unique and, most likely, similar questions are asked every day at DoD facilities around the world as canine-assisted therapy in military medicine has become more prevalent over the years. In their 2012 article, Mills and Yeager1 ting. This paper expands upon their article in light of re cent DoD and Army policy on the issue of service dogs and the use of animals in the healthcare setting. REVIEW OF THE AM ERIC A NS WITH DIS A BILITIES ACT initions are key when determining whether an animal tions would have truly helped in the given scenarios, but, covered by the ADA in terms of service animals. Sur prised? The requirements in Title II of the ADA were only applicable to public entities, and federal gov ernment agencies such as the DoD and Department of Veterans Affairs (VA) were never included in the ADA A short overview of the structure of the ADA is neces general, involved in determining an animals status as a service animal. First, the ADA is divided into 5 titles: Title I addresses Employment and Equal Employment Opportunity for Individuals with Disabilities. Very of ten, managers see this part of the law in action during employment-related actions and enforcement through the US Equal Employment Opportunity Commission. Title II deals with state and local government and affects nondiscrimination on the basis of disability in state and local government services. This title basically spells out how administrative processes are managed within state and local governments and their related organizations, Service Animals: A New Legal Dimension Within the US Military Joseph B. Topinka, JD, MHA, MBA, LLM Jack Nichols, JD Matthew Brooks, PhD, MPHScenario 1:An inpatient at a major military treatment facility (MTF) has a dog with him. No one on the ward wants to ask him whether the dog is a service animal. Instead, everyone on the ward takes turns walking the dog outside the facility until later in the day, when the charge nurse says enough. The nurse calls the command judge advocate of the medical center to confront the patient about his dog and where it will stay overnight. This is a legal issue states the charge nurse to the lawyer.Scenario 2:Months later, the same lawyer (Scenario 1 above) is having lunch in the MTF dining facility when he sees a group of people huddled together near one of the dining tables. He approaches the table, where he sees a fam ily with a basket on the table that contains a little dog that everyone thinks is adorable. Another legal issue or a public health concern?Scenario 3:A Department of Defense dependent with a service dog arrives at her school located on a military installa tion. She is wheelchair bound, and the dog has been trained to assist her with many tasks, including pulling as a service animal team, and it includes the applicable federal and state statutes. What does the principal do?

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October December 2016 109 agencies, etc. It is regulated and enforced by the Depart ment of Justice. Title III deals with public accommodations and affects nondiscrimination on the basis of disability by public accommodations and in commercial facilities. This title does not deal with government entities at all, but it is also regulated and enforced by the Department of Justice. Title IV addresses telecommunications and requires telephone and internet companies to provide individuals with hearing and speech disabilities with the ability to communicate through these media. It is regulated and enforced by the Federal Communications Commission. Title V is a miscellaneous provisions section that con tains a variety of provisions on the ADA as a whole, and it is more administrative in nature. cover any state or local government. To compound animal within the ADA statute itself. menting regulations of the ADA in Title 28 in the Code of Federal Regulations (CFR) which are written by the Department of Justice. Title II is implemented through Service animal means any dog that is individually an individual with a disability, including a physical, sen sory, psychiatric, intellectual, or other mental disability. Other species of animals, whether wild or domestic, trained or untrained, are not service animals for the pur a service animal must be directly related to the individ uals disability. Examples of work or tasks include, but are not limited to, assisting individuals who are blind or have low vision with navigation and other tasks, alerting individuals who are deaf or hard of hearing to the pres ence of people or sounds, providing nonviolent protec tion or rescue work, pulling a wheelchair, assisting an individual during a seizure, alerting individuals to the presence of allergens, retrieving items such as medicine or the telephone, providing physical support and assis tance with balance and stability to individuals with mo bility disabilities, and helping persons with psychiatric and neurological disabilities by preventing or interrupt ing impulsive or destructive behaviors. The crime deter rent effects of an animals presence and the provision of emotional support, well-being, comfort, or companion ship do not constitute work or tasks for the purposes of Section 104. In addition, both titles also address minia policies, practices, or procedures to permit the use of a miniature horse by an individual with a disability if the miniature horse has been individually trained to do work disability. rule that service animals are dogs. RE A CTION WITHIN THE FEDER A L GOVERN M ENT Since the ADA does not apply to the federal government, have executive departments such as the VA and DoD done for Veterans and service members? How have they been able to get around their limitations but at the same time create policy that is within the spirit of the ADA in regard to service animals?Department of Veterans AffairsThe VA was able to take a more direct approach through to authorize the VA to provide service dogs for Veter ans with other disabilities. The statute was originally designed to provide dogs trained to aid the blind and Hero, a trained service dog, providing comfort and emotional sup port (in the role of animal-assisted activities) at the Occupational Therapy Clinic, Walter Reed Army Medical Center. Photo courtesy of Mills and Yeager.1

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110 http://www.cs.amedd.army.mil/amedd_journal.aspxhearing impaired. The amendment broadened and Federal Register to adopt a regulation was the intent of Congress through the amendment. The VA did not implement a rule with a simply not the intent of Congress. The rule adopted (Ti Service dogs are guide or service dogs prescribed for a disabled veteran under this section. into more detail about clinical requirements, service dog ability to function as a service dog. One the one hand, the VA policy was in synch with the ADA in that it per tained directly to dogs. On the other hand, the policy focus on access to public facilities by individuals with disabilities.Department of DefenseThe DoD approach was neither direct nor simple. In fact, the DoDs approach was a patchwork effort mostly led by the Army Medical Department (AMEDD). In 2012, Watkins2 discussed policy initiatives for canines in Army medicine. Her article, along with that of Mills and Yeager,1 provided a summary of what the AMEDD pertaining to the use of canines and the use of animals in general within the healthcare setting. For example, Policy Memo 12-005 issued by the Army Medical Command (MEDCOM) in January 2012 was a com and provide clear guidance to leaders in Army medicine concerning the use of animals. It relied on past policy, past practice, research, and adopting language of the ADA as stated in Policy Memo 12-005: great a degree as is practicable and when such adherence does not hamper readiness.It was the type of guidance that would have been very useful for those of us who experienced the aforemen tioned scenarios (and other similar situations) at the time. There was simply no guidance within the military, and we had to piece together some advice based on a loose reading of the ADA along with simple common sense, which ultimately became the basis for the MED COM commanders policies. However, the MEDCOM guidance was not replicated within the other services, nor adopted by the entire US Army or DoD. Two developments have occurred since the articles by Mills and Yeager1 and Watkins2 were published: McHugh signed Army Directive 2013-014 level. The directive took some of the best aspects of the ADA and the OTSG/MEDCOM policy and made them a. Service Dogs. A service dog is a dog individually of an individual with a disability. Service dogs include guide dogs that assist individuals who are blind or have low vision with navigation and other tasks.4(p1) fense for Personnel and Readiness Brad Carson, signed Department of Defense Instruction 1300.27 Guidance on the Use of Service Dogs by Service Members. This service dogs across the entire organization, much as has establishing policy, assigning responsibility, and provid ing procedures department-wide. However, we believe short of providing the same measure of comprehensive guidance that OTSG/MEDCOM Policy Memo 12-005 provides in the medical setting. Its real focus is on the acquisition of service dogs for service members, par ticularly the standardization of that narrow issue. The Raliegh, a facility animal, providing counterbalance during a physical therapy sesson (in the role of animal-assisted therapy) at the Military Advanced Training Center, Walter Reed Army Medi cal Center. Photo courtesy of Mills and Yeager.1 SERVICE A NIMALS : A NE W LEG AL DIME NS IO N WITHIN THE US MIL IT A RY

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October December 2016 111 DoD instruction could have gone farther in providing meaningful standardization to all the services, both in side and outside of the medical setting. As written, it leaves a substantial amount of authority and discretion in developing and implementing policies regarding all animals, including service dogs, to the secretaries of the military departments. As a result, many gaps in the policy remain across DoD. UNFINISHED BUSINESS We believe that more should be done in developing and implementing service policies pertaining to service ani tion of service animals to dogs and, in some instances, miniature horses. But what about all the other animals 1 or in OTSG/MED COM Policy Memo 12-005? type of protection, why have more policies not been published or developed, not only in the medical setting but at the installation level as well? Even if the services create individual policies to address their service, the implementation of the joint-base concept prevents one on an installation controlled by another service. Should Congress be the ultimate deciding authority on this top ic as it was for the VA? These questions must necessarily be addressed in the future. REFERENCES 1. in healthcare settings. US Army Med Dep J April2. nines in Army medicine. US Army Med Dep J April-June 2012:8-11. OTSG/MEDCOM Policy Memo 12-005: Overarch ing Guidance on the Use of Animals in the Health care Setting (Service Animals, Animals Assisted Therapies, and Animal Assisted Activities). Fort Sam Houston, Texas: US Army Medical Com July 28, 2016. 4. Army Directive 2013-01 (Guidance on the Acquisi tion and Use of Service Dogs by Soldiers) Wash ington, DC: US Department of the Army; January Search/ePubsSearch/ePubsSearchDownloadPage. 2016. 5. Department of Defense Instruction 1300.27 : Guid ance on the Use of Service Dogs by Service Mem bers Washington, DC: US Department of Defense; 29, 2016. AUTHORS Mr Topinka is an assistant professor in the School of Health Administration at Texas State University where he has taught courses in various topics including em ployment law and public health. Mr Nichols is a government attorney at Headquarters, US Army Medical Command whose interest in service dogs began when nonaccredited service dog providers be gan providing untrained animals to Wounded Warriors. Dr Brooks is Director of the School of Health Adminis tration at Texas State University. He is also an Associate Professor in the School and has taught courses in various topics including healthcare strategic management, pol icy development, healthcare organization and delivery, management of health information systems, and medical informatics. Photo courtesy of COL (Ret) Elspeth Ritchie, MC, USA

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112 http://www.cs.amedd.army.mil/amedd_journal.aspxThere wasnt any bickering. There wasnt time. Everybody did their job. Were trained for emergencies. Disasters.Lt. Gelane Barron, ANC; Tripler Hospital Emergency Room1Much has been written about the military events of De cember 7, 1971; however, little has been documented about the Army nurses work and experience in Pearl Harbor, Hawaii. This paper will describe the role and experience of six Army nurses who were caring for pa cember 7, 1941. During World War I, the number of nurses in the Army Nurse Corps (ANC) grew from 403 nurses on active duty to 21,480 total nurses serving in the Great War.2 This number dramatically decreased during peacetime and the Great Depression which crippled the American economy. At the end of 1941, fewer than 1,000 ANC nurses were on active duty.3 The few military nurses who were on bases in the United States in the 1940s kept busy by treating communicable diseases and orthopedic injuries from sport or training exercises.4Several young and promising ANC nurses were sta tioned at Walter Reed Hospital, performing their regular duties as well as helping to recruit other nurses.5 In early 1941, a notice appeared asking for volunteers to serve abroad in the Philippines or Hawaii. Lt. Pauline Girard, Lt. Monica Conter, and Lt. Kathleen Coberly were look ing for opportunities to travel overseas, and volunteered to serve. That summer, they traveled together by train from Washington, DC to San Francisco to await pas sage to Hawaii on the USS Mariposa.5-7 They arrived in Hawaii on July 11, 1941.6Those nurses fortunate enough to be stationed in Ha waii were enjoying the tropical lifestyle of shorter shifts, days at the beach, and beautiful parties at beachside ho tels. Many other Navy and Army nurses arrived in Ha waii throughout 1941 in anticipation of foreign threats young women became part of the ANC; however, num bers were not yet high enough to meet the potential need should the United States become involved in the war. By Grace Under Fire: The Army Nurses of Pearl Harbor, 1941 Gwyneth R. Milbrath, RN, MSN, MPH* ABSTR A CT Objective: Much has been written about the military events of December 7, 1941; however, little has been documented history that Army nurses had been on the front line of battle. Nurses quickly triaged and stabilized those who could be saved, and provided compassion and comfort to those who were dying, in an environment where the nurses were unsure of their own survival. Methods: Traditional historical methods and a social history framework were used in this investigation. Primary sources in cluded oral histories from the US Army Medical Department Center of History and Heritage and the State of Hawaiis web site, Hawaii Aviation. Secondary sources included published books, newspaper articles, military websites, and history texts. Results: Due to the limited bed capacity, Hickam Field Hospital converted to an evacuation hospital. Nurses, physicians, and medical corpsman triaged, stabilized, and transported those likely to survive, while staging the dead behind the Hospital, collaboration between tireless doctors, nurses, and corpsmen was key to providing life-saving surgery and care. 2015Spurgeon Neel Award WinnerThe Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual Award competition for the best original article that best exemplifies the history, legacy, and tradition of the US Army Medical Department. The following article by Gwyneth Milbrath was selected as the best submission of the 2015 competition. *Ms Milbrath, an Instructor of Nursing at the University of Northern Colorado, Greeley, Colorado, is currently a doctoral student at the University of Virginia School of Nursing, Charlottesville, Virginia.

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October December 2016 113 December 1941, there were 82 Army nurses stationed in Hawaii serving at three Army medical facilities: Tripler Hospital.3 The evening of December 6th, there was an nurses attended with their dates.6-8 Lt. Conter thought the water was the most beautiful sight shed seen.5 DIS A STER STRIKES OA HU At 6 AM on the morning of December 7, 1941, six Japanese carriers positioned 200 miles north of Oahu Harbor.9 Although there were some early reports of ab normal activity the morning of December 7, the warn ing signs were unheeded and the US military forces at Pearl Harbor were taken by surprise when the Japanese 150 feet over Pearl Harbor, guns blazing, a few minutes before 8 AM that Sunday morning.9Lt. Kathryn Doody lay in bed at the nurses quarters in Fort Shafter, Hawaii, on the morning of December 7, attempting to get some extra sleep on her day off. The noise was so loud; she thought that one of the volcanoes was erupting. Fort Shafter is located in Honolulu, Hawaii, about 5.5 miles from Pearl Harbor, and was home to Tri pler Army Hospital.10 Meanwhile, Lt. Gelane Barron was already walking to work to begin her shift in the Tripler Emergency Room. Barron noticed the planes and smoke, but assumed, like many others, that the Army and Navy pilots were having maneuvers, or the US B-17 bomber planes scheduled to arrive that day were landing.1North of Tripler in the mountains of Oahu was Wheeler duty that morning, was sleeping in the barracks at Scho was so loud it shook the barracks. She tried to go back to sleep, but realizing something was wrong, she called the need of her services. Lt. Clark was told she and all other surgical nurses were to come to the OR immediately. She was out the door in two minutes, running the elevenblock distance from the barracks to the hospital. I saw what looked like big oranges on the planes and I could see two men. I dont remember being afraidthey were so close that I could hear them talking on their phones and they were right down over the hospital.8Lt. Girard was already on duty on the wards at Scho heard something crash near the building. She joined ing planes. The sergeant standing next to [her] said, Maam, cant you see the rising sun on those planes? had a big red cross on the building but they were ma 7 The Japanese were attacking the military strongholds in Oahu, including Pearl Harbor, Wheeler Air Base, and Hickam Air Base, dropping half-ton bombs and raining 11Hickam hospital was a brand new, 30-bed facility locat ed adjacent to Pearl Harbor on Hickam Army Air Base. Lt. Monica Conter was one of two nurses on duty at this small facility when the Japanese suddenly attacked the air base. As she was evacuating patients in the eleva Hickam power plant and all the clocks stopped at 7:55 AM .5 Both Hickam Field and Wheeler Army Field, along with Pearl Harbor, were priority targets for the Japa from defending against the Japanese attack force. Had could have been severely compromised. The Japanese attacked with two strikes about half an hour apart. Both Hickam and Wheeler Air Base suffered heavy damages and casualties during both strikes.11Once military leaders realized what was happening, incoming casualties. All off-duty staff were called in from their quarters, patients were discharged or moved to make room for the incoming wounded, and addition al bed spaces were created wherever there was space. When Lt. Barron walked into the ED at Tripler Hospital, it was already full of patients on litters needing care.1 load patients with litters of patients lining the halls out side the operating rooms.8 preparedness for the bombings that occurred that morn ing. Many nurses were relatively new to military nurs ing and had never been stationed outside of the United States. Some nurses felt well prepared to handle the chal lenges of that day, and others managed to adapt quickly to the changing situation and provide high-quality care to the injured soldiers. There was no formal mass casualty training, gas mask training, or basic military train ing of any sort for the nurses stationed at Pearl Harbor prior to 1942.1,10 Most nurses arrived at their duty station, were given basic lessons of Army etiquette and a couple hours of orientation to the ward, and were put to work.1

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114 http://www.cs.amedd.army.mil/amedd_journal.aspx were not trained for a mass casualty scenario, however, the hospitals were able to create more beds and had a patients.8,10 force unit, and each unit had an ambulance assigned that was able to quickly transport patients from the front lines to the hospitals.8 Despite a lack of training in mass casualty or disaster plans, the Tripler emergency room of patients arriving from Hickam and Pearl Harbor. Ev erybody knew their job. Everybody was trained for war fare and I think we worked very well as a group. There was no panic or anything.10 HICK AM FIELD HOS P IT A L The situation at Hickam Hospital was much more chaotic than Tripler Hospital due to drastic differences in staff ing, resources, and capacity. The Hickam nurses, corps men, and physicians were frantically trying to handle the hundreds of casualties on their front lawn with only the resources and space to care for 30 patients. Hickam Hos pital had only been open for three weeks, and the few nurses trained to staff the hospital were still unfamiliar with the facility. Many of the beds were still missing a they believed they would be safer from the bombings.5 began to pour into Hickam hospital. The barracks had been heavily bombed and collapsed during the attack, killing and wounding the many soldiers that were still in their rooms. Patients from the barracks had terrible crush injuries and wounds contaminated with the dust and debris from the building collapse.5 Three additional nurses, including Chief nurse Annie Fox, arrived to as sist the two nurses who were struggling to manage the and civilians arrived at Hickam in ambulances, CocaCola trucks, laundry trucks, private vehicles, and any thing else that was available.1,6 Patients were triaged as they arrived at the hospital; those still living were placed on the ground along the porch, and the dead and mortally wounded were placed behind the hospital. The nurses began stabilizing and comforting the hundreds of patients at their door as quickly as they could.5We would just go down that porch giving [morphine] shots and trying to stop the hemorrhaging and the pain on that outdoor porch with people lined up. We would give it just as fast as we could It was a thing to do in an emergency, which is an understatement. Just go ing down the porch giving those 10 shots with a 10cc we left off and gave morethats how I reacted and ev erybody else was doing it. That was the only thing we knew to do in the middle of all of this. We hoped we were saving their lives, keeping them from pain, and maybe stopping some of the hemorrhaging.5In total, 139 soldiers were killed and 303 were wound ed at Hickam Air Base, and the vast majority of these casualties would have stopped for treatment at Hickam Hospital.12 Anticipating that Hickam would become completely saturated with severely wounded soldiers, Major Frank H. Lane, commander of Hickam Field Hos pital, wisely decided to convert Hickam into an evacuation hospital, keeping only the walking wounded, and transferring all other cases to Tripler or the civilian Queens Hospital in Honolulu.6,13 TRI P LER HOS P IT A L At Tripler Hospital, the staff in the emergency room quickly triaged, stabilized, and admitted all the Soldiers coming from Hickam Field as well as some Navy Sail ors from Pearl Harbor. Those that were dead or mortally wounded were sent to a temporary morgue located be hind the hospital. Patients were then prioritized based on who needed immediate surgery that day, those who could wait until a later date, and those who could go directly to the wards. The emergency nurses continued to give the patients injections of morphine and tetanus in a similar fashion as those at Hickam. They marked their foreheads with an M or a T to document who had received these medications.1Tetanus and other infections were a chief concern of those providing wound care; however, inside the war zone sterility was not always possible. Despite using the same needle on multiple patients, no infections were reported.1,5 All soldiers would have received a tetanus immunization prior to entering the combat zone, and those with injuries from shrapnel, bullets, or other met als were given a booster vaccine. There were no deaths due to tetanus reported in Pearl Harbor. The addition of sulfa drugs in wound care drastically decreased mortal ity rates from infection in World War II compared to World War I. Oral sulfa therapy was administered both preand postoperatively. Every soldier carried a packet of sulfa drug and was instructed to take it orally as soon as he was wounded.14Despite the fear and uncertainty that most felt on De cember 7, 1941, medically trained and untrained people quickly arrived at Tripler to help manage the overwhelm ing number of casualties. Civilian volunteer nurses were automatically inducted into the ANC, and those off duty GR A CE U N DER FIRE: T H E ARMY N U RSES O F PE A RL H A RBOR, 1941

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October December 2016 115 reported immediately to help.1 Coincidently, there was a physicians convention in Honolulu that weekend, and the speaker for the morning of the bombing was deliv ering a lecture about war casualties. In the middle of this lecture, word went out to the auditorium where they were, all available doctors to report to Tripler Army Hospitalwe got lots and lots of civilian doctors that day.10 Another surgeon had presented a new way to lo cate shrapnel, and was able to use this method on many of the injured soldiers.1 A total of ten additional physi cians and six additional surgeons reported to Tripler to assist with the many casualties.15Many patients were received at Tripler with gaping wounds. Fragment wounds required immediate surgery and were sent to the operating room where Lt. Doody had just arrived and was preparing to assist as a circulat ing nurse in the OR.1,10 She scrubbed to prepare to enter the sterile operating room, she could see three patients sharing the operating room. Patients often could not be moved onto the operating tables, and their surgery was performed on the litter used to transport them into the hospital from the warzone.10 SCHOFIELD ST A TION HOS P IT A L just as busy as Tripler. Most of their patients had arrived from the nearby Wheeler Field Air Base, and had severe abdominal wounds and mangled arms and legs requir ing amputation. ANC nurse Lt. Clark immediately be gan to prepare the most critical patients for surgery. As Lt. Clark could not manage all the preparation and intra operative sedation alone. When she arrived, there were approximately 30 patients lined up along the hallway outside the OR for surgery. Volunteer physicians helped with anesthesia by giving IV anesthetics, spinal blocks, and administration of blood products; however, only those specially trained in anesthesia were able to give inhaled anesthetics. Lt. Clark described her overall ex sicians worked together as a team with some physicians prepping patients for surgery while others operated. Lt. Clark used her nursing expertise to prepare her patients both physically and spiritually for surgery. In addition to providing important therapies, she spent time talking and praying with her patients. She wanted to meet any needs her patient may have had, not just medical needs.8The medical knowledge at the time understood shock as failure of the peripheral vascular system resulting in inadequate circulation. This could be caused by loss of one to two quarts of blood; resulting in pallor, mental status changes, gasping respirations, increased heart rate, and a profound drop in blood pressure. Shock was prevented through controlling bleeding, immobilizing fractures to prevent further bleeding from movement, ids. Pain control was also an important tenant of shock prevention. Pain was understood to worsen shock, so morphine was given not only to relieve pain, but also to improve a soldiers chances of survival. Morphine was given intramuscularly in doses of a quarter to half grain, or 15-30 mg. If a Soldier were showing early signs of shock, he would be positioned with his legs above his an emergent operation. Solutions with 3%-5% glucose or 0.9% sodium chloride were given either subcutane ously or, preferably, intravenously. Intravenous (IV) lating the kidneys to remove toxins from the body. How ever, soldiers with massive bleeding saw only temporary solution would quickly leave the peripheral vascular system. For soldiers suffering from severe shock, blood products including fresh whole blood or blood plasma were key in preventing death from shock and massive hemorrhage. The technology of banking blood prod ucts was newly introduced during this period, allowing blood and plasma to be safely stored up to 8 days prior to administration.14 Many injured soldiers on leave do nated blood to repay the blood bank for blood they had received during the Pearl Harbor attacks.16 hospital beds from the exterior porch and into the mid dle of the large ward. The patients on the convalescent wards all requested to be discharged so they could go to war. Patients arrived in the ward and again required triage; some went to the OR, others to the morgue, and some stayed for wound care and to await surgery at a later date. On many wards, the physicians were unable to examine the patients until that evening because they were busy stabilizing patients in and around the operat ing room, leaving the ward under the sole care of the nurses. By the time the physicians had arrived on the ward, the patients were all undressed, sorted, assessed, and stabilized by the nurses and corpsmen.7 TR A U MA CA RE A T PE A RL HA RBOR For those Army Soldiers killed or injured, the primary mechanism of injury was the blast force and debris from the bomb, or crush injuries from structural collapse. The majority of injuries seen from an aerial bombardment consisted of multiple fractures, hemorrhage, and exten sively torn muscles, with many of those injured rapidly

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116 http://www.cs.amedd.army.mil/amedd_journal.aspxprogressing into shock. The detonation of the half-ton bombs caused the steel jacket to be blown into small, sharp fragments at a high enough velocity and rotational force to carry them over 1500 yards. The combination of the forward and rotational momentum caused severe damage to the human tissue and bone with little exter nal evidence of injury, with an estimated one-third of those wounded suffering mortal injuries. Those stand ing upright during the blast were most likely to be in jured, with wounds to the legs being most common. The recommended treatment was to splint any fracture or suspected torn muscle, provide warm blankets, sedate with morphine, and rest. Those incurring more serious injuries involving the abdomen or chest would receive surgical treatment immediately with the goal of mini mizing organ damage and internal bleeding.14Crush injuries and compound fractures were common in juries among the Soldiers in Hawaii. Crush injuries were treated by immediately compressing the effected tissue with an elastic bandage with approximately 40-60 mm Hg of pressure. This would compress the tissue enough the injured tissue, preventing gangrene. Compound frac tures were best treated in the operating theater; however, initial treatment involved splinting the affected bone, reducing the fracture if possible, applying sulfonamide powder to the wound, and covering with a dressing. Un der normal circumstances, compound fractures are a high priority for surgery; however, due to the large num ber of critical cases, most orthopedic repairs had to wait 24-72 hours. Despite this delay in treatment, no cases of gas gangrene or deaths from other infection occurred, and surgical treatment compared to World War I.14Wound care at the time heavily emphasized protection from bacteria and bleeding control. Bullets from the air the entrance wounds to appear small, and exit wounds would be several times larger.7 Direct pressure was ap plied for 2-3 minutes before bandaging to control bleed ing. For most wounds, nurses would apply a pressure dressing using a dry, sterile dressing; a freshly-ironed handkerchief; or a clean towel. If a pressure dressing was inadequate to control the bleeding, a tourniquet was applied to either the upper arm or thigh with enough pressure to compress the artery against the bone. The tourniquet was loosened every 30 minutes to reassess the wound for bleeding. If the bleeding was controlled, direct pressure to the wound and a pressure dressing injured extremity. Wounds were not routinely irrigated due to the risk of re-bleeding; rather they would sprinkle 3-10 grams of sulfadiazine into the wound, cover it with a dressing, and await surgery if needed.14Other advances in wound care included packing and dressing wounds instead of closing them with sutures. This allowed the sterile packing material to absorb in fectious drainage from the wound and decreased the incidence of wounds colonized with anaerobic bacteria, including the often fatal gas gangrene. There were only 15 cases of gas gangrene from Pearl Harbor, all from wounds prematurely closed with sutures.14 COLL A BOR A TION A ND DEDIC A TION Soldiers and medical personnel reacted both positively and negatively to the enormous amount of physical, mental, and emotional stress experienced during and following the Pearl Harbor bombing. Generally, pa tients, volunteers, and staff had a positive attitude and Hickam.7 nurses and doctors, patients, and even prostitutes came untrained volunteers assisted the effort by making 2x2 and 4x4 dressings, cotton balls, and swabs out of the bolts of gauze at the hospital; as well as cleaning, ster ilizing, and preparing the instruments in the OR at all hours of the day and night.1,8,10 tients almost ready for discharge volunteered by bring that everyone worked so well and functioned such as [she had] never seen, truly a team. They knew what to do. They knew how to do it.8 wives also volunteered at Hickam to make dressings for Soldiers, even arriving in the middle of the raid to help.5The physicians, nurses, medical corpsman, and volun teers worked together many hours past their shifts to ensure all of the patients were well-cared for, despite being understaffed and having no breaks. Lt. Girard re calls, no one had to ask you to stay on. You just stayed on until your work was doneIn the service, if youre needed, youre there. We dont have to worry about overtime, thats your job. We can work 10, 12, 14 hours and think nothing of it because [there] was something to be done.7 Following the Pearl Harbor attack, Lt. Bar ron and two other nurses covered the Tripler emergen cy room for a 20-hour shift.1 Nurses who had worked the night before stayed on until the afternoon, only to sleep and return less than eight hours later. In the OR PM that evening, and stayed on until 4:30 AM only to start more cases early the next morning.8 In many ways, the United States was unprepared and surprised by the at tack on Pearl Harbor; however, the doctors and nurses GR A CE U N DER FIRE: T H E ARMY N U RSES O F PE A RL H A RBOR, 1941

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October December 2016 117 working in the Army facilities in Hawaii were able to swiftly care for the injured soldiers. It was just a mar velous thing how they handled the emergency. We saved lives. It was somethingThey were just tremendous, and deserved to be recognized for their extraordinary 8 The staff was able to put their own personal fears and fatigue aside, work together as a team, and take care of patients without complaint. The health care team was united under the common cause themselves for their country.7,8,10In many ways, the United States was unprepared and surprised by the attack on Pearl Harbor; however, the doctors and nurses working in Hawaii that day were able to swiftly care for the injured Soldiers. In an interview 40 that day. It was just a marvelous thing how they handled the emergency. We saved lives. It was somethingThey were just tremendous, and deserved to be recognized for 8 The staff was able to put their own personal fears and fatigue aside, work together as a team, and take care of patients with out complaint. The health care team was united under the common cause of saving the lives of the soldiers who had 7,8,10The intersection of duty, resilience, and compassion shaped the nurses work at all three facilities, and their story is a testament to their dedication to others. The nurses serving in the Army hospitals at Pearl Harbor nese attack in 1941. Through triage, collaboration, sta bilization, compassion, and dedication, they saved hun dreds of lives. REFERENCES 1. Gelane Barron [Interview], May 24, 1982, 2010.8.3, 5, Research Collection, US Army Medical Department Center of History and Heritage, Fort Sam Houston, Tx.2. Army nurses of World War One: Service beyond expectations. Army Heritage Center Founda tion. Available at: http://armyheritage.org/educa tion-and-programs/educational-resources/soldierstories/130-army-nurses-of-world-war-one-ser vice-beyond-expectations.html. Accessed September 30, 2015.3. Bellafaire JA. The Army Nurse Corps: A commem oration of World War II service. US Army Center of Military History. Available at: http://www.his tory.army.mil/books/wwii/72-14/72-14.HTM. Octo ber 3, 2003. Accessed September 30, 2015.4. Sarnecky MT. A History of the US Army Nurse Corps Philadelphia, PA: University of Pennsylvania Press; 1999. pgs. 175, 177.5. Monica Conter Benning [Interview], May 26, 1982, 2010.8.3, 8, Research Collection, US Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas.6. Mary Coberly Finn [Interview], May 24, 1982, 2010.8.3, 31, Research Collection, US Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas.7. Pauline Girard [Interview], May 25, 1982, 2010.8.3, 36, Research Collection, US Army Medical Depart ment Center of History and Heritage, Fort Sam Hous ton, Texas.8. Mildred Irene Clark [Interview], May 25, 1982, 2010.8.3, 18A, Research Collection, US Army Medi cal Department Center of History and Heritage, Fort Sam Houston, Texas.9. 50th Anniversary of World War II Commemoration Committee. Pearl Harbor: 50th anniversary com memorative chronicle: A grateful nation remembers, 1941-1991 US Department of Defense; 1991. Available at: http://babel.hathitrust.org/cgi/pt?id=uiug.30 112046512148;view=1up;seq=1. Updated September 28, 1992. Accessed September 30, 2015.10. Kathryn M Doody [Interview], May 24, 1982, 2010.8.3, 27, Research Collection, US Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas.11. tory and Heritage Command. Available at: http:// www.history.navy.mil/our-collections/photogra phy/wars-and-events/world-war-ii/pearl-harbor-raid/ Ac cessed September 30, 2015.12. Hawaii Aviation. Hickam Field. State of Hawaii De partment of Transportation. Available at: hawaii.gov/ hawaiiaviation/hawaii-airfields-airports/oahu-preSeptember 30, 2015.13. Hawaii Aviation. Eye witness accounts of the bombing of Hickam AFB. Available at: http:// hawaii.gov/hawaiiaviation/world-war-ii/decem ber-7-1941/first-hand-accounts-of-the-bombing-ofhickam-afb. Accessed September 30, 2015.14. Cole W, Puestow C. First Aid: Surgical and Medical 2nd ed. London, UK: Appleton-Century Company; 1943.15. Mason VR. Medical Department United States Army in World War II pg. 627. Available at: http://history.amedd.army.mil/ booksdocs/wwii/medconslt1/Ch07.html. Accessed September 30, 2015.16. Paramount News. Sailor Repays Blood Bank [video]. GettyImages. Available at: http://www. gettyimages.com/detail/video/caravan-arrivesat-hospital-red-cross-nurses-pull-can-news-foot age/502796017. Published November 1, 1942. Ac cessed September 30, 2015.

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118 http://www.cs.amedd.army.mil/amedd_journal.aspx battle since Genghis Khan and the Mongols. They si multaneously commanded the attention of the military ant force to suffer fewer deaths from disease than from enemy action. Given the recent, disease-ridden medical debacle of the Spanish-American War, American mili tary medical reformers used Japans achievements as a model for the US Army Medical Department (AMEDD) to emulate.1 this essay reviews the failures of the AMEDD in the Spanish American War. It then highlights how Japan, ing how AMEDD reformers nonetheless used the narra tive of success to advance their own agenda in modern izing the department. JAPA NS SUCCESS A ND AM ERIC AS FA ILURE Japan and her supporters proudly trumpeted its success was evident, driving the Russians out of Korea and Manchuria and claiming the territory for themselves.2 Their conquest over disease appeared equally obvious: Japan lost more men to battle than to disease. Numbers vary based on source consulted, but whereas 53,00059,000 men died from direct enemy action, only 12,00027,000 men died from illness.3 While Japan and its al lies claimed priority for this achievement, in fact the Prussians obtained a similar ratio 30 years earlier in the Franco-Prussian War.4 Nonetheless, compared to most 19th century wars where disease far outstripped combat deaths, Japan seemed to accomplish a monumental feat. (America, for example, did not achieve similar results until World War II.) Figure 1 shows the number of dis ease deaths per battle death in wars of the 19th century. The graph highlights Japans apparent success, and it was to graphs and comparisons of this type that Japan and her supporters pointed. Reality, as this essay will prove, was more complicated. If the Russo-Japanese War was championed as a postercan War represented its alleged nadir. As Figure 1 also demonstrates, far more Soldiers died from disease in 6 Combat medicine acquitted itself well, applying the germ theory of disease through antiseptic dressings and deploying new technology like x-rays to manage the combat-wounded; the died-of-wounds rate dropped from 17% in the Civil War to 4%. However, sanitation and public health failed the American Soldier. Biv ouacked in camps that paid little heed to waste manage ment, thousands of Soldiers sufferedand diedfrom diarrhea, 74% of which resulted from typhoid.7 Until Walter Reeds team proved the role of the mosquito as a vector for yellow fever, that disease ravaged US service members as well.8 American volunteers who never left the United States also suffered grievously, as camps like Chickamauga became synonymous with death from di arrhea.9 All told, over 2500 men died from disease, com pared to 385 from combat.10Military Medicine of the Russo-Japanese War and its Influence on the Modernization of the US Army Medical Department Justin Barr, MD*2015Spurgeon Neel Annual Award Runner-upThe Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual Award competition for the best original article that best exemplifies the history, legacy, and tradition of the US Army Medical Department. The following article by Dr Justin Barr was selected as the second best submission of the 2015 competition. *Dr Barr is with the Department of Surgery, Duke University Medical Center, Durham, North Carolina.

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October December 2016 119 The debacle of American military medicine in the Span ish American War spawned reform efforts in the Army Medical Department. In the immediate post-war years, searing public commentary led to the Dodge Commis sion investigating the reasons behind the failure of the Army and its medical support. Presented in February of 1899, the Report delivered a fair, impartial accounting. Surgeon General William Sternberg and the AMEDD escaped most of the blame, with responsibility assigned to Congress for not funding the department adequately and restricting the number of regular Army physicians.11 military, with poor relations between line and staff of issue not totally resolved until the Elihu Roots restruc turing of the Army.12 The Army kept enough line of tained enough surgeons for only for 42,000 men.13 Con tract surgeons hired to make up the difference had little experience in public health, contributing to the deadly diarrheal epidemics. Effective as physicians, they failed 14 Military surgeons from Sternberg on down wanted Congress to fund a reserve corps of Army doctors that would allow better trained Army physicians to deploy in time of war.15 They intro duced multiple congressional bills demanding a larger, better trained cadre of uniformed physicians.16AMEDD reformers used the apparent success of the Jap anese to promote their agenda and provide evidence for Other nations, including so poor a nation as the Japa in the shape of a large and well organized medical ser vice, noted Army Surgeon General Robert OReilly, implying that America should as well.17 Even outside military medicine, American Medical Association Pres ident William Mayo used the success of the Japanese as 18 By 1907, The Surgeon Generals Index contained almost 500 articles on the Russo-Japanese war, highlighting the attention it received in the medical community. No one lionized the Japanese more than Louis L. Sea men. Having served as a volunteer surgeon in the Span ish American War, Seaman travelled to Manchuria as their war with Russia. He returned to publish gushing accounts of their ability to control disease.19 Seaman ex plicitly strove to force change in the AMEDD, dedicating of the Japanese Army, who have proved that the normal condition of the Soldier is health; to that vast army of American Dead, whose lives in war have been needlessly incompetency.20 most importantly, their effective integration with line of measures, all features deemed lacking in the AMEDD.Figure 1. Disease deaths per battle deaths by 19th century war and combatant, showing the apparent success, though not priority, of the Japanese.5 FPW indicates Franco-Prussian War; SAW, Spanish American War; UK, United Kingdom; CSA, Confederate States of America. Disease Deaths per 1 Battle Death War and Countries Involved 4 1 0 2 6 3 5 7 8 9 1.7 0.5 0.3 0.5 7.9 1 1.9 3.8 7.3 2.1 FPW SAW Russia Union USA Boer War Crimea USA CSA UK German Japan Russia UK and France Mexican War US Civil War Russo-Japanese War

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120 http://www.cs.amedd.army.mil/amedd_journal.aspxPart of the western acceptance of Japanese medicine stemmed from its adoption of modern germ-based medicine. Early Portuguese and Dutch traders to Japan contributed little medical knowledge, but the opening of Japan by Commodore Matthew Perry and especially the Meiji Restoration of 1868 provided an institutional and intellectual framework for western medicine to take hold.21 As Germany dominated medical research in the late 19th century, Japan emulated the Teutonic system. German professors like Karl Leopold Mueller travelled to Japan to establish a medical education system. Stellar Japanese students studied and worked in German labo ratories. Kitasato Shibasaburo, perhaps the best known Japanese scientist, studied with Robert Koch, produced 22 He became world famous, sharing the star-billet with Jo seph Lister at an 1891 London conference. Kitasato and colleagues like Ogata Masanori, who also studied with Koch and Max Petternkoffer, brought the gospel of bac teriology back to Japan, where it was widely accepted.23 their public health efforts in the Russo-Japanese War. Efforts started in training camp, where the Japanese Surgeon General distributed pamphlets to each recruit instructing them to cook their food thoroughly, boil their drinking water, seek medical care early, and avoid 24 These pam phlets explicitly based their recommendations on the germ theory of disease imported from Germany. The and here the Japanese propensity for bathing greatly as sisted in camp hygiene.25 This educational effort contin lectures to reinforce these concepts.26In addition to (and arguably more important than) their role in treating combat wounded, Japanese medical sponsibilities.27 Physicians accompanied foraging par ties to check food quality; they inspected provisions; they established and monitored sewer and latrine sys tems in the camp; and when the Japanese captured a troops occupying the village to ensure sanitation pre vailed. They performed their jobs effectively because experts whose advice was to be heeded. This respect that of the line. Japanese physicians most important task lay in main taining a potable water supply.28 Per Surgeon General Shigemichi Suzuki, the paramount importance of good water supply in military sanitation was recognized drinking unboiled water was strictly forbidden even in peace time and this rule was strenuously applied in the late war.29 The Japanese custom of tea consump tion helped ensure boiled water.30 regulated well-water quality. When they came across a new water source, they used their bacteriology-based laboratory training to test its contents and regulate its use (see Figure 2).31 American reformers recognized the importance and proper emphasis on public health in the Japanese Army. Colonel John Hoff believed Japans success stemmed solely from the observance of wellestablished hygienic rules [and] proper sanitary organi zationthis war has developed nothing new in medical treatment or surgical technique, its one lesson for us is summed up in a single word: prevention [emphasis original].32The Japanese might have achieved greater success had they vaccinated their troops. Almroth Wright developed the typhoid vaccine in 1897. It was available to, but not mandatory for, the British Army during the Boer War. Figure 2. Left: signs posted at water sources in Japan indicating water purity. Right: an American attach points to one such sign posted at a well. MIL I T AR Y ME DI C INE OF THE R USS O-J A P A NE S E W AR A N D I T S INFL U ENCE ON THE MO DE R NI Z A T I ON OF THE US A RM Y ME DI C A L DEP AR T MENT

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October December 2016 121 About 5% of British Soldiers chose to be vaccinated; thousands of others perished from the disease.33 Given the impact of disease in the Spanish American and Boer Wars, typhoid commanded substantial attention in the military medical literature.34 Articles variously sup ported and decried vaccination.35 The Japanese opposed it, with Surgeon General Suzuki categorically stating that preventive inoculations were not performedpre ventive inoculation for typhoid fever, dysentery, cholera, and plague not yet being certain.36 Eschewing the chol era vaccine had minimal impact on their forces.37 They did mandate smallpox vaccinations and as a result suf fered only 209 cases with 12 deaths from the disease.38 Based largely on the experience of the British and Japa cination in 1911.39While the Japanese achieved measureable success ly white rice, resulted in tens of thousands of unneces sary casualties. Beriberi had bedeviled Asian societies cal debate traversed Europe and Asia, with apostles of bacteriology claiming to identify a causative microor ganism whereas other scientists insisted on a nutritional Christiaan Eijkman proved the disease resulted from the lack of vitamin B1, though it took decades for his hypothesis to gain acceptance).40 Polished, white rice lacks vitamin B1; it was also more expensive and thus a status symbol in Japan. As such, for much of history only upper-class Japanese suffered from the disease. The Army and Navy, trying to elevate social position of soldiers and sailors, transitioned to polished, white rice in the late 19th century only to see the incidence of beriberi soar among their forces. With out identifying the precise etiology, the Japanese Navy recognized the correlation between white rice and the disease, added barley to their rations in 1886, and effec tively eliminated the problem. The Japanese Army, how ever, remained wed to an infectious etiology and did not alter their rations until February of 1905.41 By then, over 80,000 Japanese soldiers required evacuation from the theater for beriberi; around 10,000 of those men died.42 CONCLUSIONS: VA RYING DEFINITIONS OF SUCCESS The Japanese recognized and touted their military medi cal accomplishment. They claimed their ability to con trol disease was an essential factor in their victory over the numerically superior Russians: Russia may be able to place 2,000,000 men in the ery war four men die of disease for every one who falls from bullets. That will be the position of Russia in this war. We propose to eliminate disease as a factor. Every man who dies in our Army must fall the superiority of Russian numbers and stand on a comparatively equal footing.43In fact, Russian forces in theater did not outnumber the Japanese, and the Russians achieved similar success in perception of Jap anese success not only elevated Japans standing among modern nations but also served as evidence for Ameri can military medical reformers. The conclusion of this article examines Japans claims of medical superiority strating how Americans like Seamen used the notion of Japanese superiority to effect real change in the AMEDD. While the Japanese undeniably lost more men to battle than to disease, a more sophisticated analysis of their ca sualty statistics undermine their claims of military med ing in this era, with leaders like Karl Pearson, Francis Galton, and Charles Davenport, later infamous for their work on eugenics, devising and publishing powerful new methods of analyzing numerical data in their new, 1901 journal Biometrika .44 Applying even rudimentary biostatistics shows that the disease death:battle ratio is ants medical service and leads to inaccurate conclusions when comparing one war against another. First, it does not account for either the size of the army or the length of the war. Reassessing Japans losses from dis ease while taking into account these variables reveals a notable lack of distinction. As Figure 3 shows, Japan lost proportionately the same number of men from dis ease as other 19th century combatants. Secondly, the ratio ignores differences in battle deaths among wars, the crucial denominator in this fraction. deaths from illness appear as either a disaster or tri umph of military medicine. The high number of casual ties the Japanese suffered offset their losses from sick ness. Almost 60,000 Japanese Soldiers and sailors died from battle wounds, a rate of 54 deaths per 1000 men per year. As Figure 4 shows, this rate was higher than all other 19th century military engagements except for the Crimean and Franco-Prussian Wars. War led to this high casualty rate. The combat forecast the trench warfare of World War I, with the Russians with water cooled machine guns, barbed wire-laced

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122 http://www.cs.amedd.army.mil/amedd_journal.aspx batteries.45 Japan assaulted across no-mans-land in rigid, Prussian formations, taking thousands of casualties. Even Ian Hamilton, a British military disastrous landings at Gallipoli, reported the Japanese are lavish with their brave infantry, and think little of losing two or three hundred men.46 ease deaths:battle deaths and made Japanese military medicine appear more effective than it actually was. Perceptions matter as much as reality in history, and the perceived notion of Japanese success fol lowing American failure helped catalyze reforms of the AMEDD .47 Seaman certainly propagated this mantra of Japanese superiority, reporting numbers highlighting their achievement. Not all of Seamans contemporaries accepted his statis tics even when they agreed with his overarching goal of AMEDD reform. Charles Stokes, the Sur geon General of the American Navy at the time, commented, Dr. Seaman, whose aims seem per fectly proper, can do the cause of military surgery and military sanitation in this country no greater service than that of correcting his statistics and removing the wrong impressions some of his remarks have made.48 And Lewis Duncan later published an exhaustive review of casualty statis tics in part to counter the ridiculously false idea that the Americans in Spanish American War portionally, as the Japanese in their recent war.49 Despite some countervailing views, the trope of Japanese success persisted (and has endured into the present).50The AMEDD successfully used this narrative to foster multiple reforms in the early 20th century. A 1901 reorganization of the AMEDD stemmed but failed to address numerical shortages and es pecially relations with the line.51 Japans apparent achievements in 1904-1905 provided new am Rider Teddy Roosevelt arguing for the AMEDD in front of Congress, the legislative body added 123 billets to the department in 1908. A reserve medi cal corps was established to avoid again relying on un trained contract surgeons. Japans demonstration of the importance of sanitation War established a department of military hygiene at the United States Military Academy at West Point.52 In 1907, both the Army Staff College and the Army War College initiated courses on sanitation.53 military recognition of the salience of public health Figure 3. Death rates per 1000 men in the Army per year, demonstrating Japanese equivalence to other 19th century combatants, including the US Army in the Spanish American War. SAW indicates Spanish American War; UK, United Kingdom. SAW French USA Japanese Boer War Franco-Prussian War Union UK Russian German US Civil War Russo-Japanese War 25.58 80 20 0 40 120 60 100 140 160 Deaths/1000/Annum War and Countries Involved 13.5 25 140.8 24.51 65 25.73 MIL I T AR Y ME DI C INE OF THE R USS O-J A P A NE S E W AR A N D I T S INFL U ENCE ON THE MO DE R NI Z A T I ON OF THE US A RM Y ME DI C A L DEP AR T MENT 30 10 50 0 40 20 60 80 70 SAW French USA Japanese Boer War Franco-Prussian War Union UK Russian German US Civil War Russo-Japanese War 35 54 War and Countries Involved Deaths/1000/Annum 14 4.6 67.5 55 33 Figure 4. The rates of combat deaths, elucidating the high relative casualty rate suffered by the Japanese. SAW indicates Spanish American War; UK, United Kingdom.

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October December 2016 123 measures and further elevated the stature of uniformed physicians as specialists and equals who could provide the expertise necessary to keep an army intact. These reforms contributed to the marked success of the AMEDD in World War I where the American Expedi tionary Force managed to limit deaths from disease to fewer than those from combat.54 Victor Vaughan, who, along with Walter Reed had investigated the typhoid outbreaks at Chickamauga and again donned a uniform in 1917, remarked: I served in the war with Spain in made certain requests or offered certain advice. As a rule, I was snubbedbut in the late war [World War I] I had a different experience. I never went to a line of it will be done.55 The perceived and propagandized to reforms in the US Army and AMEDD that provided the foundation for this change in attitude and change in care, as uniformed American physicians could now ENDNOTES 1. British military medical reformers, embarrassed after the disease-ridden Boer War, did the same. See Claire Herrick, The Conquest of the Silent Foe: British and American Military Medical Reform Rhetoric and the Russo-Japanese War, in Medicine and Modern War fare, edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 99-130 (Atlanta: Rodopi, 1999). 2. The best single volume history of the Russo-Japanese War remains Dennis and Peggy Warner, The Tide at Sunrise: a History of the Russo-Japanese War (New 3. For 53,000 battle deaths and 12,000 disease deaths, see Louis Livingstone Seaman, The Real Triumph of Japan: the Conquest of the Silent Foe Appelton and Co., 1907) 510. For 59,000 and 27,000, see Louis C. Duncan, The Comparative Mortality of Disease and Battle Casualties in the Historic Wars of the World, Journal of the Military Service Institution of the United States 54, no. 188 (1914): 172. 4. Roger Cooter, Of War and Epidemics: Unnatural Couplings, Problematic Conceptions, Social History of Medicine 16 no. 2 (2003): 292. Duncan, The Com parative Mortality of Disease and Battle Casualties in the Historic Wars of the World, 169. 5. M. R. Smallman-Raynor and A. D. Cliff, War Epidem ics (Oxford: Oxford University Press, 2004). 6. For the best history of military medicine in the Spanish American War, see Vincent J. Crillo, Bullets and Bacil li: The Spanish-American war and Military Medicine (New Brunswick: Rutgers University Press, 2004). For coverage of the Philippines theater, see Warwick Anderson, Colonial Pathologies: American Tropical Medicine, Race, and Hygiene in the Philippines (Dur ham: Duke University Press, 2006), chapters 1 and 2. For an overview of the AMEDD in this era, see Mary C. Gillet, The Army Medical Department 1865-1917 (Washington DC: Center of Military History, 1995) chapters 5-11. J. T. H. Connor, Before the World in Concealed Disgrace, Physicians, Professionalization and the 1898 Cuban Campaign of the Spanish Ameri can War, in Medicine and Modern Warfare edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 29-58 (Atlanta: Rodopi, 1999). 7. Crillo, Bullets and Bacilli 138. 8. in the Spanish American War, see Espinosa, Mariola. Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878-1930 (Chicago: University of Chicago Press, 2009). Multiple works have exam ined Walter Reeds efforts, including: Howard A. Kel ly, Walter Reed and Yellow Fever 2nd ed. (Baltimore: The Medical Standard Book Company, 1906) and John R. Pierce and Jim Writer, Yellow Jack: How Yellow Fe ver Ravaged America and Walter Reed Discovered Its Deadly Secret (New Jersey: John Wiley & Sons, 2005). 9. Connor, Before the World in Concealed Disgrace, 36-37. 10. Americas Wars, http://www.va.gov/opa/publications/ factsheets/fs_americas_wars.pdf (accessed 27 Sep tember 2015). 11. The AMEDDs lack of control over supplies also damned their effort to provide adequate care. Stephen C. Craig, In the Interest of Truth: the Life and Science of Surgeon General George Miller Sternberg (Fort Sam Houston: Borden Institute Press, 2013) chapter 12. Cirillo, Bullets and Bacilli chapter 5. 12. Russel F. Weigley, History of the United States Army 13. Major W. C. Borden, Minutes from the meeting of The Association of Military Surgeons, Journal of the Association of Military Surgeons Vol. 17 (1905-06): 530. 14. Anderson, Colonial Pathologies 30-32. 15. Letter from George Sternberg to the Adjutant General of the Army, Journal of the Association of Military Surgeons XIII (1903-04): 325-27. Azel Ames, A Med ical Reserve Corps for the Army of the United States, Journal of the Association of Military Surgeons XVI (1904-05): 69-94. Army Medical Reorganization, Journal of the Association of Military Surgeons XVI (1904-05): 63. 16. See, for example, Bill for the Increase of the Medical Department of the Army, Journal of the Association of Military Surgeons XII (1903-1904): 327-330.

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124 http://www.cs.amedd.army.mil/amedd_journal.aspx17. Quoted in Bobby A. Wintermute, Public Health and the U.S. Military: a History of the Army Medical De partment, 1818-1917 See also Jefferson Randolph Kean, Journal of the As sociation of Military Surgeons XVIII (1905-06): 1-35. 18. William J. Mayo, The Medical Profession and the Issues Which Confront It, Journal of the American Medical Association XLVI, no. 23 (1906): 1737-1740. 19. Publications include: Louis Livingston Seaman, Shall Disease Triumph in Our Army? A Plea for Recognition of the Medical Department of the United States Army man, From Tokyo Through Manchuria with the Japa nese. Seaman, Observations in the Russo-Japanese War. Louis Livingston Seaman, The Real Triumph of Japan or the Conquest of the Silent Foe. Journal of the Association of Military Surgeons 17 (1905-06): 500-30. Seaman, The Real Triumph of Japan Louis Livingston Seaman, The Prevention of Disease in the War: More Power for the Medical Department of Defense Society, Inc., 1918). Louis Livingston Seaman, and War in Foreign Lands, with Suggestions upon the Necessity of Important Changes in the Organization of the Medical Department of the United States Army. 20. Seaman, The Real Triumph of Japan opening dedication. 21. Harold Cook, Matters of Exchange: Commerce, Medi cine, and Science in the Dutch Golden Age (New Ha Gordon, A Modern History of Japan: from Tokugawa Times to the Present Press, 2003) 61-76. Albert Craig, The Central Gov ernment, in Marius Jansen and Gilbert Rozman, eds, Japan in Transition (Princeton: Princeton University Press, 1986) 36-67. 22. Anna Jannetta has recently complicated this simplis tic periodization by carefully examining the intro duction of smallpox vaccination western medicine in both theory and practice in the early 19th century. See The Vaccinators: Smallpox, Medical Knowledge, and the Opening of Japan (Stanford: Stanford Uni versity Press, 2007). However, smallpox vaccination represents more the exception than the rule, with even Jannetta acknowledging that Japans emperor banned western medicine, except for vaccination; it did create a bridgehead that facilitated the introduction of bacte riology later in the century. 23. William W. Ford, Bacteriology Hoeber, 1939) 114. 24. John Z. Bowers, When the Twain Meet: The Rise of Western Medicine in Japan (Baltimore: The Johns Hopkins University Press, 1980). 25. Fluency in German was required of Japanese physi cians so they could access the latest bacteriological re search. The Preparation of the Japanese Medical Of Journal of the Association of Military Surgeons 18 (1905-06): 292-293. 26. Seaman, The Real Triumph of Japan 167-68. Seaman provided a translated copy of the hand-out. 27. Valery Havard, The Sick and Wounded in the Rus so-Japanese War, Journal of the Association of Mili tary Surgeons 17 (1905-06): 546. Seaman, The Real Triumph of Japan 151-52. David Walder, The Short 1905 (London: Hutchinson & Co., 1970) 223. Walder related a humorous anecdote where, during the winter time, Japanese Soldiers would sprint, naked, from the heated bath houses to their barracks across the freez ing Manchuria plains a show of true dedication to cleanliness! 28. Shigemichi Suzuki, Note on the Sanitary Condition of the Imperial Japanese Army During the Late RussoJapanese War, Journal of the Association of Military Surgeons XIX no. 5 (November 1906): 433. Suzuki was the Surgeon General of the Japanese Navy during the Russo-Japanese War. 29. For the Japanese emphasis on preventive medicine and sanitation, see John van Rensselaer Hoff, The Japa nese as Military Sanitarians, Journal of the Associa tion of Military Surgeons XIV (1903-04): 379-80. 30. Seaman, From Tokyo to Manchuria with the Japanese 232-33. Seaman, Observations in the Russo-Japanese War, 21-22. Seaman, The Real Triumph of Japan 117, 146-47. Friedrich Prinzing, Epidemics Resulting from Wars (London: Oxford at the Clarendon Press, 1916) 297. 31. Suzuki, Note on the Sanitary Condition of the Impe rial Japanese Army During the Late Russo-Japanese War, 434-35. 32. John van Rensselaer Hoff, Medico-Military Notes in Manchuria, Journal of the Association of Military Surgeons XIX (1906): 112. The Japanese and Russian Military Medical Matters, Journal of the Association of Military Surgeons XIV (1903-04): 182. Prinzing, Epidemics Resulting From Wars 297. 33. Seaman, The Real Triumph of Japan 154. A Report from Vice Admiral Kataoka, Commander in Chief 3rd Squadron, in M. Kinai, The Russo-Japanese War: (Tokyo: The Shimbashido, 1905) 57. During the winter, the ground froze for several meters; this layer of frozen earth prevented ground water from seeping in and contaminating wells. Havard, The Sick and Wounded in the Russo-Japanese War, 538. 34. Dysentery proved the most deadly infectious disease for Japan, killing over 6,000 Soldiers. Prevalence of Disease: War and Infectious Disease Before 1914, MIL I T AR Y ME DI C INE OF THE R USS O-J A P A NE S E W AR A N D I T S INFL U ENCE ON THE MO DE R NI Z A T I ON OF THE US A RM Y ME DI C A L DEP AR T MENT

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October December 2016 125 Public Health Reports 56 (21 March 1941): 549. Kean, The Prevention of Disease in the Army and the Best Method of Accomplishing that Result, 33. Hoff, Medico-Military Notes in Manchuria, 121-28. Prinz ing, Epidemics Resulting From Wars 297. Seaman, The Real Triumph of Japan 106. 35. Hoff, Medico-Military Notes in Manchuria, 97-98. 36. Michael Worboys, Almroth Wright at Netley: Mod ern Medicine and the Military in Britain, 1892-1902, in Medicine and Modern Warfare edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 77-98 (At lanta: Rodopi, 1999) 88-90. 37. Much discussion in the medical and especially the military medical profession focused on typhoid and particularly on causation and vectors. For the seminal work at the time, see Walter Reed, Victor Vaughan, and Edward Shakespeare, Report on the Origin and Spread of Typhoid Fever in US Military Camps during the Spanish War of 1898 (Washington DC: Govern Prize winning essay by Frederick Smith, The Dif ferential Diagnosis of Typhoid Fever, Journal of the Association of Military Surgeons XIV (1903-1904): 69-94. 38. Some articles suggested an innate Japanese immunity to typhoid explained their ability to control the disease. Some Considerations Connected with the Relative Im munity of the Japanese Armies from Typhoid Fever, Lancet 165 no. 4264 (20 May 1906): 1365-66. 39. E. H. Wilson, Anti-typhoid Inoculations, Journal of the Association of Military Surgeons XIII (1903-04): 79-80. 40. Compulsory vaccination was rare in all countries at this this time, with the practice being the subject of much debate. See, for example, Peter Baldwin, Conta gion and the State in Europe, 1830-1930 (Cambridge: Cambridge University Press, 1999) chapter 4. 41. Suzuki, Note on the Sanitary Condition of the Impe rial Japanese Army During the Late Russo-Japanese War, 436. 42. There is a suggestion that Japan did use some chol era vaccines (see Prevalence of Disease, 500), but no hard evidence to substantiate this claim. For a contemporary evaluation of cholera vaccination, see Edward Shakespeare, Report on Cholera in Europe and India 1890) 502-03, 548-55, 576, 625-26, 629-30, 660, and especially Chapter VI, entitled Preventive Inocula tion of Cholera. 43. Hoff, Medico-Military Notes in Manchuria, 129. Havard, The Sick and the Wounded in the Japanese War, 535. Seaman, The Real Triumph of Japan 22435. Suzuki, Note on the Sanitary Condition of the Im perial Japanese Army During the Late Russo-Japanese War, 436. Seaman discusses the presence of a factory in Japan that produced the smallpox vaccination. 44. Stanhope Bayne-Jones, The Evolution of Preventive Medicine in the United States Army, 1607-1939 (Wash 45. Kenneth J. Carpenter, Beriberi, White Rice, and Vi tamin B: A Disease, a Cause, and a Cure (Berkeley: University of California Press, 2000). 46. This insistence on a bacterial etiology for beriberi was not at all unique to the Japanese but rather represented a common view throughout Europe and America, too. K Codell Carter, The Germ Theory of Disease, Beri Medical History 21 (1977): 119-136. 47. Alan Hawk, The Great Disease Enemy, Kakke (Beri beri) and the Imperial Japanese Army, Military Medi cine 171 no. 4 (April 2006): 333-339. 48. Quoted in Seaman, From Tokyo through Manchuria with the Japanese 240. Seaman does not provide a source for the quote. 49. David Salsburg, The Lady Tasting Tea: How Statistics Revolutionized Science in the Twentieth Century (New medical statistics in the 19th century, see John M. Eyler, Victorian Social Medicine: the Ideas and Methods of William Farr (Baltimore: the Johns Hopkins Univer sity Press, 1979), especially chapter 2. Both accounts demonstrate the over-simplicity and thus inaccuracy of the battle deaths:disease deaths ratio, and thus its inappropriateness a metric of success for comparing wars. 50. Hydraulic and mechanical recoil systems for artillery appeared in the 1870s, allowing for a higher rate of cal authorities noticed and explored in their writings. For the role of artillery in the Russo-Japanese War, see Lessons of the RussoJapanese War translated by: E. Louis Spiers (London: Hugh Rees, Ltd. 1906) 42-54. Also, L. Z. Soloview, Actual Experiences in War: Battle Action of Infantry; Impressions of a Company Commander translated by the War Department (Washington DC: United States Army General staff, 1906) 6. Francis Roger Sedge wick, The Russo-Japanese War: A Sketch: First Peri od The Concentration (London: Swan Sonnenschien & Co., 1909) 192. Walder, The Short Victorious War 291. Hoff, Medico-Military Notes in Manchuria, 131. Charles S. Butler, Wounds Produced by Japanese Projectiles, Journal of the Association of Military Surgeons 18 (1905-06): 284. Hoff, Medico-Military Notes in Manchuria, 136, 139. Seaman, From Tokyo to Manchuria with the Japanese 48. Seaman, The Real Triumph of Japan or the Conquest of the Silent Foe, 541; H. Nimier, Wounds by Artillery Projectiles,

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126 http://www.cs.amedd.army.mil/amedd_journal.aspxHand Grenades and Land Mines in the War in Man churia, Translated by Charles Wilcox. Journal of the Association of Military Surgeons XVIII (1905-06):166, 122. 51. Quoted in Sedgwick, The Russo-Japanese War: A Sketch 191. See also Ian Hamilton, Scrapbook During the Russo-Japanese War (London: E. Arnold, 1907). 52. Jay Winter has pioneered the importance of histori cally contrived memory of war over factual reality. See, for example, his book Sites of Memory, Sites of Mourning: the Great War in European Cultural His tory 53. See minutes to the meeting of the Association of Mili tary Surgeons in Journal of the Association of Military Surgeon Vol. 17, pp. 520-22 and p. 502. 54. Duncan, Comparative Mortality of Disease and against the absurd conclusion[s] of by Homer Lea. Leas arithmetic is correct, but Lea does not factor other variables into his equations. Seamans numbers corresponded closely with those of Lea. Interestingly, this essay won the Seaman Prize, even as it contra dicted much of Seamans earlier work. It does not cite Seaman. 55. Many modern military medical histories still accept Japanese medical victory and priority in the RussoJapanese War uncritically. See, for example, Carol R. Byerly, U.S. Army during World War I University Press, 2005) 51. Wintermute, Public Health and the US Military 162. Gillet, The Army Medical Department, 1865-1917 325. 56. Connor, Before the World in Concealed Disgrace, 50. 57. Instruction in Hygiene at West Point, Journal of the Association of Military Surgeons 17 (1905-06): 148. A Department of Military Hygiene at West Point, Jour nal of the Association of Military Surgeons 17 (190506): 475. 58. Wintermute, Public Health and the U.S. Military 169. 59. Mary C. Gillet, The Army Medical Department, 1917(Washington DC: Center of Military History, American Expeditionary Forces in France During the First World War, MA thesis, Command and General Staff College, 1991. 60. Quoted in Paul Starr, The Social Transformation of American Medicine: The Rise of a Sovereign Profes sion and the Making of a Vast Industry Basic Books, 1982), 141. Starr argues that this trans ability of the medical profession military and civilian over these years. See also Conner, Before the World in Concealed Disgrace, 50. WORKS CITED Americas Wars. http://www.va.gov/opa/publications/ factsheets/fs_americas_wars.pdf (accessed 27 September 2015). Ames, Azel. A Medical Reserve Corps for the Army of the United States. Journal of the Association of Military Surgeons XVI (1904-05): 69-94. Anderson, Warwick. Colonial Pathologies: American Tropical Medicine Race and Hygiene in the Philippines Durham: Duke University Press, 2006. Army Medical Reorganization. Journal of the Association of Military Surgeons XVI (1904-05): 63. Baldwin Peter. Contagion and the State in Europe, 18301930. Cambridge: Cambridge University Press, 1999. Bayne-Jones, Stanhope. The Evolution of Preventive Medicine in the United States Army, 1607-1939. Washington Bill for the Increase of the Medical Department of the Army. Journal of the Association of Military Surgeons XIII (190304): 327-30. Borden, W. C. Minutes from the meeting of The Association of Military Surgeons, Journal of the Association of Military Surgeons, Vol. 17 (1905-06): 520-530. Bowers, John Z. When the Twain Meet: The Rise of Western Medicine in Japan Baltimore: The Johns Hopkins University Press, 1980. Butler, Charles S. Baron Takaki on the Health of the Japanese Navy. Journal of the Association of Military Surgeons XIX no. 3 (September 1906): 327. Byerly, Carol R. the US Army during World War I University Press, 2005. Carpenter, Kenneth J. Beriberi, White Rice, and Vitamin B: A Disease, a Cause, and a Cure. Berkeley: University of California Press, 2000. Carter, K. Codell. The Germ Theory of Disease, Beriberi, Medical History 21 (1977): 119-136. Physicians, Professionalization and the 1898 Cuban Campaign of the Spanish American War. In Medicine and Modern Warfare, edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 29-58. Atlanta: Rodopi, 1999. Cook, Harold. Matters of Exchange: Commerce, Medicine, and Science in the Dutch Golden Age University Press, 2007. Cooter, Roger. Of War and Epidemics: Unnatural Couplings, Problematic Conceptions. Social History of Medicine 16 no. 2 (2003): 283-302. MIL I T AR Y ME DI C INE OF THE R USS O-J A P A NE S E W AR A N D I T S INFL U ENCE ON THE MO DE R NI Z A T I ON OF THE US A RM Y ME DI C A L DEP AR T MENT

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October December 2016 127 Craig, Albert. The Central Government. In Japan in Transition, edited by Marius Jansen and Gilbert Rozman, 36-67. Princeton: Princeton University Press, 1986. Craig, Stephen C. In the Interest of Truth: the Life and Science of Surgeon General George Miller Sternberg. Fort Sam Houston: Borden Institute Press, 2013. A Department of Military Hygiene at West Point. Journal of the Association of Military Surgeons 17 (1905-06): 475. Duncan, Louis C. The Comparative Mortality of Disease and Battle Casualties in the Historic Wars of the World. Journal of the Military Service Institution of the United States 54 no. 188 (March-April 1914): 141-176. Espinosa, Mariola. Epidemic Invasions: Yellow Fever and the Limits of Cuban Independence, 1878-1930 Chicago: University of Chicago Press, 2009. Eyler, John M. Victorian Social Medicine: the Ideas and Methods of William Farr. Baltimore: the Johns Hopkins University Press, 1979. Ford, William W. Bacteriology 1939. Gillet, Mary C. The Army Medical Department 1865-1917 Washington DC: Center of Military History, 1995. Washington DC: Center of Military History, 2009. Gordon, Andrew. A Modern History of Japan: From Tokugawa Times to the Present University Press, 2003. Hamilton, Ian. Russo-Japanese War. London: E. Arnold, 1907. Havard, Valery. The Sick and Wounded in the RussoJapanese War. Journal of the Association of Military Surgeons 17 (1905-06): 531-46. Hawk, Alan. The Great Disease Enemy, Kakke (Beriberi) and the Imperial Japanese Army. Military Medicine 171 no. 4 (April 2006): 333-39. and American Military Medical Reform Rhetoric and the Russo-Japanese War. In Medicine and Modern Warfare, edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 99-130 (Atlanta: Rodopi, 1999). Hoff, John van Rensselaer. The Japanese as Military Sanitarians. Journal of the Association of Military Surgeons XIV (1903-04): 379-84. Medico-Military Notes in Manchuria. Journal of the Association of Military Surgeons XIX no. 2 (August 1906): 97-141. Instruction in Hygiene at West Point. Journal of the Association of Military Surgeons 17 (1905-06): 148. Expeditionary Forces in France During the First World War. MA thesis, Command and General Staff College, 1991. Janetta, Anna. The Vaccinators: Smallpox, Medical Knowledge, and the Opening of Japan Stanford: Stanford University Press, 2007. The Japanese and Russian Military Medical Matters. Journal of the Association of Military Surgeons XIV (190304): 181-83. Kean, Jefferson Randolph. The Prevention of Disease in the Army and the Best Method of Accomplishing that Result. Journal of the Association of Military Surgeons 18 (1905-06): 1-35. Baltimore: The Medical Standard Book Company, 1906. The Shimbashido, 1905. Letter from George Sternberg to the Adjutant General of the Army. Journal of the Association of Milita ry Surgeons XIII (1903-04): 325-27. Mayo, William J. The Medical Profession and the Issues Which Confront It. Journal of the American Medical Association XLVI, no. 23 (1906): 1737-1740. Lessons of the Russo-Japanese War. Translated by: E. Louis Spiers. London: Hugh Rees, Ltd., 1906. Nimier, H. Wounds by Artillery Projectiles, Hand Grenades and Land Mines in the War in Manchuria. Translated by: Charles Wilcox. Journal of the Association of Military Surgeons 18 (1905-06): 116-24. Pierce, John R. and Jim Writer. Yellow Jack: How Yellow Fever Ravaged America and Walter Reed Discovered Its Deadly Secret. New Jersey: John Wiley & Sons, 2005. Journal of the Association of Military Surgeons 18 (1905-06): 292-93. Prevalence of Disease: War and Infectious Disease Before 1914. Public Health Reports 56 (21 March 1941): 548-73. Prinzing, Friedrich. Epidemics Resulting from Wars. London: Oxford at the Clarendon Press, 1916. Reed, Walter, Victor Vaughan, and Edward Shakespeare. Report on the Origin and Spread of Typhoid Fever in US Military Camps during the Spanish War of 1898. Washington Salsburg, David. The Lady Tasting Tea: How Statistics Revolutionized Science in the Twentieth Century Henry Holt and Company, 2001. Seaman, Louis Livingston. From Tokyo through Manchuria with the Japanese 1905.

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128 http://www.cs.amedd.army.mil/amedd_journal.aspxObservations in the Russo-Japanese War. Journal of the Association of Military Surgeons XVI (1904-05): 1-32. The Prevention of Disease in the War: More Power for the Medical Department of the Army, Pamphlet No. 25. New The Real Triumph of Japan or the Conquest of the Silent Foe. Journal of the Association of Military Surgeons 17 (1905-06): 500-30. The Real Triumph of Japan: The Conquest of the Silent Foe Shall Disease Triumph in Our Army? A Plea for Recognition of the Medical Department of the United States Army. New War in Foreign Lands, with Suggestions upon the Necessity of Important Changes in the Organization of the Medical Elliot Publishing Company, 1908. Sedgwick, Francis Roger. The Russo-Japanese War: A Sketch: First Period The Concentration London: Swan Sonnenschien & Co., 1909. Shakespeare, Edward. Report on Cholera in Europe and India Smallman-Raynor, M.R. and Cliff, A.D. War Epidemics. Oxford: Oxford University Press, 2004. Smith, Frederick. Differential Diagnosis of Typhoid Fever. Journal of the Association of Military Surgeons XIV (190304): 69-94. Soloview, L. Z. Actual Experiences in War: Battle Action of Infantry; Impressions of a Company Commander. Translated by the War Department. Washington DC: United States Army General Staff, 1906. Some Considerations Connected with the Relative Immunity of the Japanese Armies from Typhoid Fever. Lancet 165 no. 4264 (20 May 1906): 1365-66. Starr, Paul. The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry Suzuki, Shigemichi. Notes on the Experiences During the Russo-Japanese Naval War, 1904-1905. Journal of the Association of Military Surgeons 17 (1905-06): 420-49. Note on the Sanitary Condition of the Imperial Japanese Army During the Late Russo-Japanese War. Journal of the Association of Military Surgeons XIX no. 5 (November 1906): 431-36. Walder, David. The Short Victorious War: The Russo. London: Hutchinson & Co., 1973. Warner, Dennis and Peggy. The Tide at Sunrise: a History of the Russo-Japanese War Weigley, Russel F. History of the United States Army. New Wilson, E. H. Anti-Typhoid Inoculations. Journal of the Association of Military Surgeons XIII (1903-04): 79-84. Winter, Jay. Sites of Memory, Sites of Mourning: the Great War in European Cultural History University Press, 1995. Wintermute, Bobby A. Public Health and the US Military: A History of the Army Medical Department, 1818-1917 New Worboys, Michael. Almroth Wright at Netley: Modern Medicine and the Military in Britain, 1892-1902. In Medicine and Modern Warfare, edited by Roger Cooter, Mark Harrison, and Steve Sturdy, 77-98. Atlanta: Rodopi, 1999.MIL I T AR Y ME DI C INE OF THE R USS O-J A P A NE S E W AR A N D I T S INFL U ENCE ON THE MO DE R NI Z A T I ON OF THE US A RM Y ME DI C A L DEP AR T MENT

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