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U.S. Army Medical Department journal

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

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

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

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Source Institution:
University of Florida
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University of Florida
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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 )

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Preceded by:
Journal of the US Army Medical Department.

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Digital Military Collection

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THE MUL T IDISCIPLINARY ASPEC T S OF PUBLIC HEAL T H J OURNAL THE UNITED STATES ARMY MEDICAL DEPARTMENT January-June 2018 First Record of Aedes ( Stegomyia ) malayensis Colless (Diptera: Culicidae) in the Lao Peoples Democratic Republic, Based on Morphological Diagnosis and Molecular Analysis . . . . 1 Maysa T. Motoki, PhD; Elliott F. Miot, MS; Leopoldo M. Rueda, PhD; et al Mosquito Surveillance Conducted by US Military Personnel in the Aftermath of the Nuclear Explosion at Nagasaki, Japan, 1945 . . . . . . . . . . . . 8 David B. Pecor, BS; Desmond H. Foley, PhD; Alexander Potter Georgias Collaborative Approach to Expanding Mosquito Surveillance in Response to Zika Virus: Year Two . . . . . . . . . . . . . . . . . . 14 Thuy-Vi Nguyen, PhD, MPH; Rosmarie Kelly, PhD, MPH; et al An Excel Spreadsheet Tool for Exploring the Seasonality of Aedes Vector Hazard for User-Specified Administrative Regions of Brazil . . . . . . . . . . . . 22 Desmond H. Foley, PhD; David B. Pecor, BS Surveillance for Scrub Typhus, Rickettsial Diseases, and Leptospirosis in US and Multinational Military Training Exercise Cobra Gold Sites in Thailand . . . . . . . 29 Piyada Linsuwanon, PhD; Panadda Krairojananan, PhD; COL Wuttikon Rodkvamtook, PhD, RTA; et al Risk Assessment Mapping for Zoonoses, Bioagent Pathogens, and Vectors at Edgewood Area, Aberdeen Proving Ground, Maryland . . . . . . . . . . 40 Thomas M. Kollars, Jr, PhD; Jason W. Kollars Optimizing Mission-Specific Medical Threat Readiness and Preventive Medicine for Service Members . . . . . . . . . . . . . . . 49 Public Health Response to Imported Mumps CasesFort Campbell, Kentucky, 2018 . . . . 55 Developing Medical Surveillance Examination Guidance for New Occupational Hazards: The IMX-101 Experience . . . . . . . . . . . . . . . . . 60 W. Scott Monks, MPAS, PA-C Missed Opportunities in Human Papillomavirus Vaccination Uptake Among US Air Force Recruits, 2009-2015 . . . . . . . . . . . . . . . 67 Barriers to Physical Activity Among Military Hospital Employees . . . . . . . . 76 Darren Hearn, DPT, MPH; Anna Schuh-Renner, PhD; Michelle Canham-Chervak, PhD, MPH; et al Hydration Strategies for the Female Tactical Athlete . . . . . . . . . . . 83 Spurgeon Neel Annual Writing Award Top Essays Americas Guerilla Hospitals in the Vietnam War: the CIDG Experience . . . . . . 91 Justin Barr, MD Ambiguous Duty: Red Cross Nurses and the First World War . . . . . . . . 99 The Figures of Experience: A Brief History of Risk and Planning Within the Army Medical Community . . . . . . . . . . . . . . . 106

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J OURNAL A Prof essional Publication of the AMEDD Community THE UNITED STATES ARMY MEDICAL DEPARTMENT Online issues of the AMEDD Journal are available at http://www.cs.amedd.army.mil/amedd_journal.aspx JanuaryJune 2018 US Army Health Readiness Center of Excellence PB 8-18-1/2/3/4/5/6 The Army Medical Department Journal [ISSN 1524 0436 ] is published quarterly for The Surgeon General by the Borden Institute, USAMEDDC&S, DOTAA 3630 Stanley RD Attn: AMEDD JRNL, JBSA Fort Sam Houston, TX 78234 6100 Articles published in The Army Medical Department Journal are listed and indexed in MEDLINE, the National Library of Medicines premier bibliographic database of life sciences and biomedical information. As such, the Journal s articles are readily accessible to researchers and scholars throughout the CORRESPONDENCE: receive copies, and unit address changes or deletions should be sent via email to usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil, or by regular mail to the above address. Telephone: (210) 221-6301, DSN 471-6301 DISCLAIMER: The AMEDD Journal presents clinical and nonclinical professional information to expand knowledge of domestic & international military medical issues and technological advances; promote collaborative partnerships among Services, components, Corps, and specialties; convey clinical and health service support information; and provide a peer-reviewed, high quality, print medium to encourage dialogue concerning healthcare initiatives. Appearance or use of a commercial product name in an article published in the AMEDD Journal does not imply endorsement by the US Government. the Navy, Department of the Air Force, Department of Defense, nor any other agency of the US Government. The content does not change or supersede information in other US Army Publications. The AMEDD Journal reserves the right to edit all material submitted for publication (see inside back cover). CONTENT: Content of this publication is not copyright protected. Reprinted ma-terial must contain acknowledgement to the original author(s) and the AMEDD Journal OFFICIAL DISTRIBUTION: This publication is targeted to US Army Medical Department units and organizations, other US military medical organizations, and members of the worldwide professional medical community. By Order of the Secretary of the Army: GERALD B. OKEEFE Secretary of the Army Mark A. Milley 1806411 LTG Nadja Y. West MG Patrick D. Sargent Edward A. Lindeke Richard Burton

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January June 2018 1 The Nakai Nam Theun National Protected Area (NNT NPA), known as the Watershed Management and Pro tection Authority area bordering Vietnam, is located in Nakai District, Khammuane Province, Lao Peoples Democratic Republic (PDR). It is an important South east Asian biodiversity area, containing mammals, birds, reptiles, amphibians, 1 and insects, including mosquitoes. It is also the home of a number of rare or newly discov ered species of animals. 2-5 Rueda et al 6 reported a total of 101 species from Laos, including newly recorded Aedes ( Stegomyia ) species collected from Khammuane province, ie Aedes ( Stego myia ) albopictus (Skuse) and Ae. ( Stg. ) pseudoscutel laris (Theobald), and those reported in the literature, ie, Ae. ( Stg. ) aegypti (Linnaeus), Ae. gardnerii imitator (Leicester), Ae. ( Stg. ) seatoi Huang, Ae. ( Stg. ) annanda lei (Theobald), Ae. ( Stg. ) craggi (Barraud), Ae. ( Stg. ) ma likuli Huang Ae. ( Stg. ) perplexus (Leicester), Ae. ( Stg. ) desmotes (Giles), Ae. ( Stg. ) pseudalbopictus (Borel). 7-9 All voucher specimens of these newly recorded species, as reported by Rueda et al, 6 were deposited in the Smith sonian Institution, National Museum of Natural History, Washington, DC, and in the Entomology Laboratory, In stitut Pasteur Laos. Tangena et al 10 added an additional 51 species to the list of Lao mosquito fauna. However, all voucher specimens from that report were, unfortu nately, damaged or lost, and we were not able to conduct any further morphological examinations or DNA analy sis of those specimens from this study. The subgenus Stegomyia of genus Aedes has 128 valid species worldwide, 11 with 24 species found in the Great er Mekong subregion of Asia (Cambodia, China, Laos, Myammar, Thailand, and Vietnam), including 12 spe cies from Lao PDR. Several species of subgenus Stego myia are major vectors of various organisms that cause human infectious diseases such as dengue, yellow fever, 12-14 Aedes aegypti is the primary vector of dengue through out the tropical and subtropical regions of the world. 15 Aedes albopictus is also an important vector in dengue epidemics. 16-18 Aedes malayensis Colless is widely dis tributed in many parts of Asia, 19 particularly Cambodia, India, Malaysia, Singapore, Taiwan, Thailand, and Viet nam. 11 A recent study showed a high susceptibility of Ae. malayensis and its vectorial capacity for both dengue se rotype 2 and chikungunya. 20 This species is recorded for Ae. malayensis from Laos based on the cytochrome c oxidase subunit I ( COI ) mitochondrial gene and the morphological diagnostic characteristics of adults, and compared them with Ae. albopictus MATERIALS AND METHODS Specimen Collection Larvae of mosquitoes were collected from aquatic habitats along the Nam Noy River (17.768548N, 105.381989E), Lao PDR (Figure 1) in March 2017, using standard larval dippers (350 ml, 13 cm diam ( BioQuip, First Record of Aedes ( Stegomyia ) malayensis Colless (Diptera: Culicidae) in the Lao Peoples Democratic Republic, Based on Morphological Diagnosis and Molecular Analysis Maysa T. Motoki, PhD Khamsing Vongphayloth, MD Mustapha Debboun, PhD Leopoldo M. Rueda, PhD Khaithong Lakeomany, BS Paul T. Brey, PhD ABSTRACT Aedes ( Stegomyia ) malayensis Colless from the Lao Peoples Democratic Republic. Its larvae were collected from rock pools and rock holes along the Nam Noy River in the Nakai Nam Theun National Protected Area, Khammuane Province. Larvae were reared in the laboratory and emerged mitochondrial cytochrome c oxidase subunit I. Detailed photographs of the morphological diagnostic charac ters and information on the bionomics of Ae malayensis are included.

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2 http://www.cs.amedd.army.mil/amedd_journal.aspx transferred into a WhirlPak plastic bag (BioQuip) using pipettes, and transported to the laboratory of Institut Pasteur du Laos. Morphological Identification Emerged adults were pinned on paper points, each giv en a unique collection number, properly labeled, and Tokyo, Japan) following the morphological keys of Rat tanarithikul et al. 21 Voucher specimens were deposited in the Entomology Collection, Institut Pasteur du Laos, Vientiane, Lao PDR, and the National Mosquito Collec tions of the Smithsonian Institution, National Museum of Natural History, Washington, DC. Diagnostic charac ters of Ae. malayensis adults were photographed. DNA Extraction and Sequencing Total genomic DNA was extracted from a single whole mosquito using Macherey-Nagel NucleoSpin Tissue (GmbH & Co KG, Duren, Germany) according to man ufacturers instructions. The fragment of mitochondrial cytochrome c oxidase subunit I (mtDNA COI ) gene was 22 The PCR protocol consisted of a one minute denaturation at 94C and 5 cycles at 94C for 40 seconds, 45C for 40 seconds and 72C for one minute, followed by 30 cy cles at 94C for 40 seconds, 49C for 40 seconds and 72C for one minute, and a 5-minute extension at 72 C. The PCR amplicons were electrophoresed in 1.5% TAE agarose gels stained with GelRed Nucleic Acid Gel products were then cleaned by add the thermocycler and ran at 37C for 30 minutes, followed by 80 C for 15 minutes. All sequencing reactions were con ducted in both directions using the original primers and the Big Dye Ter minator Kit v.3.1 (PE Applied Bio on an ABI Prism 3500xL Avant Ge were edited in Sequencher v.5.4.6 (Genes Codes Co, Ann Arbor, MI, 9.1.6. 23 A bootstrapped 24 Neighbor Joining tree 25 was used based on 1,000 replicates. The evolutionary distances were calcu lated using the Kimura-2 parameters method 26 conduct ed in MEGA v.7. 27 All 658 base pair (bp) of the barcode fragment were included in pairwise comparisons. Two sequences of Ae. albopictus were used as an outgroup. RESULTS Morphological Diagnosis The adult Ae. malayensis is very similar to Ae. albopictus, except for the diagnostic characters given below 21 : 1. A supraalar area of thorax with a patch of pale scales extended toward the scutellum in Ae. malayensis and a supraalar area of thorax with spot of pale scales not extended toward the scu tellum in Ae. albopictus (Figure 2); 2. Abdominal terga IV-VI with dorsal white bands connected to lateral pale patches in Ae. malayensis and abdominal terga IV-VI with dorsal white bands separated from lateral spots in Ae. albopictus (Figure 3). Furthermore, the adults of Ae. malayensis are very simi lar to adults of Ae. alcasidi Huang, Ae. riversi Bohart and Ingram and Ae. scutellaris (Walker) and share the following diagnostic characters 19 : 1. Midfemur without median white line on anterior surface; 2. Wing with minute basal spot of white scales on costa; and 3. Hindtarsomere 5 entirely white. 19 we did not have samples of Ae. alcasidi Ae. riversi, FIRST RECORD OF AEDES ( STEGOMYIA ) MALAYENSIS COLLESS (DIPTERA: CULICIDAE) IN THE LAO PEOPLES DEMOCRATIC REPUBLIC, BASED ON MORPHOLOGICAL DIAGNOSIS AND MOLECULAR ANALYSIS AU Attapeu HO Houaphan OU Oudomsouk VI Vientiane (VC Vientiane Capital) BO Bokeo KH Khammuane PH Phongsaly XA Xayabury BL Borikhamxay LO Louangnamtha SA Saravane XE Sekong CH Champasak LP Luang Prabang SV Savannakhet XI Xieng Khouang Figure 1 Sampling location of Ae. malayensis in the Lao PDR.

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January June 2018 3 or Ae. scutellaris to compare, but we present the photographs of those diagnostic characters of Ae. malayensis from the Lao PDR (Figure 4). Bionomics Larvae (n=31) of Ae. malayensis were collected in the NNT NPA from rock holes and rock pools along the edges of the Nam Noy River, in an open area between the river and the forest. The habitats were not complete ly shaded, but some of them were naturally shaded by the rocks with fresh, clean, and cool water, and without vegetation (Figure 5) Larvae of Ae. al bopictus were also collected from the same hab itats in association with Ae. malayensis Adults (n=17) of Ae. malayensis were collected using sweep nets near larval habitats. Adult females were attracted to humans and fed on their blood. Molecular Characterization The fragment of COI was sequenced for 4 specimens of Ae. malayensis and 2 specimens of Ae. albopictus were used as an outgroup (GenBank numbers: MG921172-MG921178). We compared them with the DNA barcode sequences of our samples with those published previously (KY420809, KY420810, KY420811; KR349280, KR349282). 20 The amplicon length of the barcode sequence of Ae. malayensis was consistent at 658 bp (without primers). The base compositions were similar for all specimens, 14.31% G, 15.98% C, 29.22% A, and 40.49% Ae. malayensis female adult compared with Ae. albopictus (Figure 6). CO MM ENT Larvae of Ae. malayensis have been found in tree holes in Singapore and Taiwan, and in coconut shells in Viet nam. In Thailand, they were found in rock holes, rock pools, water jars, and bamboo cups, while in Malaysia they were collected from rock pools, bamboo stumps, a 19 In the Lao PDR, Ae. malayensis was found in rock pools (Figure 5) and rock holes together with Ae. albopictus This sympatry A B Figure 2 Morphological comparison of the thorax. (A) Ae. malayensis a supraalar area of thorax with a patch of pale scales extended upward toward the scutellum. (B) Ae. albopictus a supraalar area of thorax with spot of pale scales not extended toward the scutellum. A B Figure 3 Morphological comparison of the abdominal terga IV-VI. (A) Ae. malayensis dorsal white bands connected to lateral pale patches. (B) Ae. albopictus dorsal white bands separated from lateral spots.

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4 http://www.cs.amedd.army.mil/amedd_journal.aspx was also observed in Singapore, Malaysia, Thailand, and Taiwan. 19,28 The larval habitat along the Nam Noy River is approximately 40 km from the nearest urban could only be accessed by a 3-hour boat trip. Larvae of Ae. malayensis are morphologically similar to Ae. albopictus each other. 28 The body ornamentations of the adults and larvae are highly variable. 28 Despite the fact that Ae. albopictus is very similar to Ae. malayensis the combination of some distinct morphological characters 21 (Figures 2 and 3). Likewise, the adults of Ae. malayensis are very similar to adults of Ae. alcasidi Ae. riversi, and Ae. scutellaris 19 particularly the wings, midfemur, and hindtarsomere 5 (Figure 4). Ae malayensis its abdominal ornamentation (Figure 3). DNA barcoding of the mitochondrial COI has been an 29-31 Herein, the ob the COI sequences. The COI sequences of Ae. malayen sis from Lao PDR were clustered with the COI sequenc es of the Singapore samples, and distinguished from the Ae. albopictus Ae. malayensis in the Lao PDR (Figure 6). Dengue, chikungunya, Zika, and yellow fever viruses are the most important pathogens associated with the species of subgenus Stegomyia 14,32 Because of the im portant role of Aedes ( Stegomyia ) species in arbovirus transmission, Huang 28 larvae and pupae, and redescribed both adult sexes of Ae. malayensis from samples collected from the type locality in Pulau Hantu, Singapore. Even though the medical importance of Ae. malayensis was not well known at the time, it was found to have strong anthropophilic behavior in Bo-Pia, Prachuap Khiri Khan, Thailand, 19 and India, 33 as well as our recent observations in Nakai, along the Nam Noy River. In addition, Rosen et al 34 reported that Ae. malayensis was susceptible to all 4 serotypes of dengue virus after oral infection, but the presence of virus in the mosquito saliva was not determined. Moreover, Mendenhall et al 20 compared the vector competence of Ae. albopictus and Ae. malayensis with Ae. aegypti from Singapore after oral infection with dengue serotype 2 and chikungunya viruses and observed the high susceptibility of Ae. malayensis and Ae. albopictus to both arboviruses. FIRST RECORD OF AEDES ( STEGOMYIA ) MALAYENSIS COLLESS (DIPTERA: CULICIDAE) IN THE LAO PEOPLES DEMOCRATIC REPUBLIC, BASED ON MORPHOLOGICAL DIAGNOSIS AND MOLECULAR ANALYSIS A B C Figure 4 Morphological characters of Ae. malayensis that are similar to Ae. alcasidi Ae. riversi and Ae. scutellaris : (A) Midfemur without median white line on anterior surface. (B) Hindtarsomere 5 entirely white. (C) Wing with minute basal spot of white scales on costa.

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January June 2018 5 Importantly, the saliva of infected Ae. malayensis contained infectious particles for both viruses. This provided the evidence that Ae. malayensis and Ae. albopictus from Singapore possess all the necessary traits to transmit these arboviruses. Aedes malayensis remains an understudied species of Stegomyia although it is found in Singapore, Malaysia, Thailand, Cambodia, Vietnam, Taiwan, China (Hain an), 19,29,35 India, 33 and now in the Lao PDR. Because of the wide distribution of Ae. malayensis in many parts of Asia, 19 its high vector competence, 20,34 and its anthro pophilic behavior, 19,33 more studies are warranted on the Stegomyia species as an arbovirus vector in the Lao PDR. ACKNOWLEDG M ENTS shed Management and Protection Au our research in the WMPA area and provided technical support during the tance; and the Institut Pasteur du Laos study. Special thanks go to Dr Sandra Nagaki for reviewing this manuscript and for her valuable comments. We also appreciate the input of Louis Lam brechts of the Insect-Virus Interaction group of the Institut Pasteur de Paris. This study was partially supported by Two, work unit number D1428, in sup port of the Military Infectious Diseases Research Program and Institut Pasteur du Laos. REFERENCES 1. Wildlife Conservation Society. Nakai Nam Theun National Protected Area [internet]. 2017. Available at: https://laos.wcs.org/ Saving-Wild-Places/Nakai-Nam-Theun-NPA.aspx Accessed December 12, 2017. 2. Musser GG, Smith AL, Robinson MF, Lunde DP. Description of a new genus and species of rodent (Murinae, Muridae, Rodentia) from the Kham mouan Limestone National Biodiversity Con servation Area in Lao PDR. Am Mus Novitates 2005;3497:1-31. 3. Luu VQ, Truong QN, Thomas C, et al. New coun try records of reptiles from Laos. Biodivers Data J 2013;1:e1015. 4. Luu VQ, Nguyen TQ, Le MD, Bonkowski M, Ziegler T. A new species of karst-dwelling bent-toed gecko (Squamata: Gekkonidae) from Khammouane Province, central Laos. Zootaxa 2016;4079(1):87-102. Figure 5 Larval habitats (rock holes) of Ae. malayensis in the Nakai District. Figure 6 Bootstrapped NJ tree using COI sequences of Ae. malayensis (MG 921172 MG 921176 = Lao PDR; KY 420809 -KY 420811 =Singapore 20 ) based on 1 000 replicates of Tamura-Nei algorithm. Bootstrap values less than 50% are not shown. Scale bar represents sequence ( % ) divergence between samples. Ae. albopictus (MG 921177 MG 921178 ) was used as an outgroup. MG921178 Ae. albopictus MG921177 Ae. albopictus MG921173 Ae. malayensis MG921174 Ae. malayensis MG921175 Ae. malayensis MG921176 Ae. malayensis KY420811 Ae. malayensis KY420809 Ae. malayensis KY420810 Ae. malayensis 0.0100 100 99 82

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6 http://www.cs.amedd.army.mil/amedd_journal.aspx 5. Luu VQ, Nguyen TQ, Le MD, Bonkowski M, Ziegler T. A new karst dwelling species of the Gekko japonicus group (Squamata: Gekkonidae) from central Laos. Zootaxa 2017;4263(1):179-193. 6. Rueda LM, Vongphayloth K, Pecor JE, et al. Mos quito fauna of Lao Peoples Democratic Republic, with special emphasis on the adult and larval sur veillance at Nakai District, Khammuane Province. US Army Med Dep J. July-September 2014;25-32. 7. Apiwathnasorn C, ed. A List of Mosquito Species in Southeast Asia 8. Tsuda Y, Kobayashi J, Nambanya S, et al. An eco logical survey of dengue vectors in Central Lao PDR. Southeast Asian J Trop Med Public Health 2002;33:63-67. 9. Vythilingam I, Sidavong B, Thim CS, Phonemixay mosquitoes of Attapeu Province, Laos People Democratic Republic. J Am Mosq Control Assoc 2006;22:140-143. 10. Tangena JAA, Thammavong P, Malaithong N, et al. Diversity of mosquitoes (Diptera: Culicidae) attracted to human subjects in rubber plantations, secondary forests, and villages in Luang Prabang Province, Northern Lao PDR. J Med Entomol 2017;1-16. 11. log of Culicidae (database on line). Suitland, MD: Institution; 2015. Available at: http://www.mosqui tocatalog.org Accessed January 3, 2018. 12. Peters W. A Colour Atlas of Arthropods in Clini cal Medicine 1992. 13. Huang Y-M. The subgenus Stegomyia of Aedes in the Afrotropical Region with keys to the species (Diptera: Culicidae). Zootaxa 2004;700:1-120. 14. subgenus Stegomyia of Aedes gion with keys to the species (Diptera: Culicidae). Contr Am Entomol Inst 1979;165(6):1-79. 15. Chow VTK, Chan YC, Yong R, et al. Monitoring of Aedes aegypti and Aedes albopictus polymerase chain reaction and cycle sequencing. Am J Trop Med Hyg 1998;58:578-586. 16. Com parative role of Aedes albopictus and Aedes ae gypti in the emergence of dengue and chikungu nya in central Africa. Vector Borne Zoonotic Dis 2010;10(3):259-266. 17. Tomasello D, Schlagenhauf P. Chikungunya and dengue autochthonous cases in Europe, 2007-2012. Travel Med Infect Dis 2013;11(5):274-284. 18. Lai S, Huang Z, Zhou H, et al. The changing epide miology of dengue in China, 1990-2014: a descrip tive analysis of 25 years of nationwide surveillance data. BMC Med 2015;13(1):1-12. 19. Huang Y-M. Contributions to the mosquito fauna Stegomyia of Aedes in Southeast Asia. I-The scutellaris group of species. Contr Am Entomol Inst 1972;9(1):1-109. 20. Mendenhall IH, Manuel M, Moorthy M, et al. Peri domestic Aedes malayensis and Aedes albopictus are capable vectors of arboviruses in cities. PLoS Negl Trop Dis. 2017;11(6):e0005667. 21. Rattanarithikul R, Harbach RE, Harrison BA, Panthusiri P, Coleman RE, Richardson JH. Illus trated keys to the mosquitoes of Thailand VI. Tribe Aedini. Southeast Asian J Trop Med Pub Health 2010;41(suppl 1):1-225. 22. drial cytochrome c oxidase subunit I from diverse Mol Mar Biol Biotechnol 1994;3:294-299. 23. Kearse M, Moir R, Wilson A, et al. Geneious Ba sis: an integrated and extendable desktop software quence data. Bioinformatics 2012;28:1647-1649. 24. nies: An approach using the bootstrap. Evolution 1985;39:783-791. 25. Saitou N, Nei M. The neighbor-joining method: a new method for reconstructing phylogenetic trees. Mol Biol Evol 1987;4:406-425. 26. Kimura M. A simple method for estimating evolu tionary rate of base substitution through compara tive studies of nucleotide sequences. J Mol Evol 1980;16:111-120. 27. Kumar S, Stecher G, Tamura K. MEGA7: molecu lar Evolutionary Genetics Analysis version 7.0 for bigger datasets. Mol Biol Evol 2016;33:1870-1874. 28. Huang Y-M. A redescription of Aedes ( Stego myia ) scutellaris malayensis Colless and the dif ferentiation of the larva from that of Aedes ( S .) albopictus (Skuse). Proc Entomol Soc Washington 1971;73(1):1-8. 29. mosquito species in China based on DNA barcod 30. Linton YM, Pecor JE, Porter CH, et al. Mosqui bionomics and barcodes. Mem Inst Oswaldo Cruz 2013;108(I):100-109. FIRST RECORD OF AEDES ( STEGOMYIA ) MALAYENSIS COLLESS (DIPTERA: CULICIDAE) IN THE LAO PEOPLES DEMOCRATIC REPUBLIC, BASED ON MORPHOLOGICAL DIAGNOSIS AND MOLECULAR ANALYSIS

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January June 2018 7 31. Chan A, Chiang LP, Hapuarachchi HC, et al. DNA barcoding: complementing morphological identi Paras Vect 2014;7:569. 32. Huang Y-M. The subgenus Stegomyia of Aedes in the Afrotropical Region. I. The africanus group of species (Diptera: Culicidae). Contr Am Entomol Inst. 1990;26(1):1-90. Available at: www.dtic.mil/ get-tr-doc/pdf?AD=ADA511785. Accessed June 14, 2018. 33. Tewari S, Hiriyan J, Reuben R. Epidemiology of subperiodic Wuchereria bancrofti infection in the Nicobar Islands, India. Trans R Soc Trop Med Hyg 1995;89(2):163-166. 34. Chaniotis BN. Comparative susceptibility of mos quito species and strains to oral and parental infec tion with dengue and Japanese encephalitis viruses. Am J Trop Med Hyg 1985;34(3):603-615. 35. Colless DH. Notes on the taxonomy of the Aedes scutellaris Group, and new records of A. paullusi and A. albopictus (Diptera: Culicidae). Proc Linn Soc N S W 1962;312-315. Available at: https://ar chive.org/details/biostor-86217. Accessed June 14, 2018. AUTHORS Dr Motoki and Mr Miot share lead author responsibility for this report. Dr Motoki is a Research Entomologist of Institut Pasteur du Laos, Vientiane, Lao PDR, and formerly was Post doctoral Entomologist of the Department of Entomology, Smithsonian Institution, Museum Support Center, Suit land, Maryland. AUTHORS (continued) France, working at the Institut Pasteur du Laos, Vien teractions Group, Department of Genomes and Genetics, Institut Pasteur, Paris, France, and the Centre National 2000, Paris, France. Dr Rueda is an Adjunct Scientist of the Smithsonian Institution and formerly was Research Entomologist and ogy Branch, Walter Reed Army Institute of Research located at the Smithsonian Institution Museum Support Center, Suitland, Maryland. Dr Vongphayloth is a Medical Doctor and Entomologist of Institut Pasteur du Laos, Vientiane, Lao PDR. Mr Phommavanh is an Assistant Technical Entomologist of Institut Pasteur du Laos, Vientiane, Lao PDR. Mr Lakeomany is an Assistant Technical Entomologist of Institut Pasteur du Laos, Vientiane, Lao PDR. Dr Debboun is Director of the Mosquito and Vector Control Division, Harris County Public Health, Houston, Texas. Navy Region Center, Sembawang, Singapore. Dr Brey is a Research Entomologist and Director of Institut Pasteur du Laos, Vientiane, Lao PDR. Articles published in the Army Medical Department Journal are indexed in MEDLINE, the National Library of Medicines bibliographic database of life sciences and biomedical information. Inclusion in the MEDLINE database ensures that citations to AMEDD Journal

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8 http://www.cs.amedd.army.mil/amedd_journal.aspx a nuclear bomb over the city of Nagasaki, Japan, mark ing only the second (and last) time a nuclear weapon was rendered to Allied forces, ending World War II (WWII). pan) President Harry Truman selected General Doug las A. MacArthur to supervise the Allied occupation of Japan. During this occupation in the months after the with developing and implementing a mosquito control plan for Japan. 1 Challenges related to mosquito control abounded in postwar Japan, many of which had been building during the years leading up to the end of the war. In 1942, there was a Dengue fever outbreak report ed from Nagasaki, however, with the destruction of cities and the displacement of populations, information about Dengue fever incidence before American occupation is limited. 2 According to La Casse, 1 Japanese informants claimed that Dengue fever was completely unheard of in Japan before 1942, 1 but approximately 13,000 Dengue fever cases were reported in that year. It is important to note that many houses in Japan were required to keep wartime and these containers were perfect habitat for container-breeding mosquitoes such as Aedes albopic tus Skuse. 2 these containers. 2 sites included cemeteries, particularly for Ae. albopic tus and Ae. togoi (Theobald). Although each gravesite may only have provided habitat for a few larvae, large number of these breeding sites meant large populations of mosquitoes in cities like Nagasaki. 2 Gray articulated this challenge eloquently, while commenting generally on this challenge impacting people across the world: It is a strange commentary on human intelligence that the graves of the dead are permitted to bring death, disease and discomfort to the living. 2 Mosquitoes collected from foul-water, including liquid manure tanks, posed sites for species such as Culex quinquefasciatus Say, Cx. pipiens Linnaeus, and Armigeres species. 2 Finally, rice paddies are of particular concern for the malaria vec tor, Anopheles sinensis Wiedemann sensu lato in and around Nagasaki. Mosquitoes that breed in containers, polluted water, and rice paddies were the primary con cerns for Nagasaki under Allied occupation. In a 1947 Army 207th Malaria Survey Detachment (MSD), CPT Walter La Casse, noted that there was great concern in early 1946 that an epidemic of Japanese encephalitis (JEV) was a major threat to American forces occupy ing mainland Japan. 1 Thus, a plan was developed to col lect as much bionomics data as possible to help develop mosquito abatement plans. The 207th MSD stationed in Kyoto, Japan, conducted mosquito surveys from 19461949. 3 Mosquito taxonomy in Japan was not well estab cies were described from the islands; however, by 1959, the total number of species known from Japan was 45. 3 surveillance in the city of Nagasaki during Allied occu pation of Japan. The specimens of interest were donated Mosquito Surveillance Conducted by US Military Personnel in the Aftermath of the Nuclear Explosion at Nagasaki, Japan, 1945 David B. Pecor, BS Desmond H. Foley, PhD Alexander Potter ABSTRACT plans. Thus, surveillance was conducted in the months following Allied occupation of Japan at the conclusion of World War II. Mosquito surveillance in Nagasaki, Japan, began one month after the nuclear bomb destroyed condition as part of the process for making them readily available to researchers.

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January June 2018 9 tion by Charles A. Triplehorn in November 1973, and are part of the personal collection of Dr Donald J. Bor ror who is most famous for his work using bioacoustics to track bird distributions. However, in 1945, Dr Borror 4 In cor respondence with the South East Asia Mosquito Project (later redesignated as the Walter Reed Biosystematics paper records by Triplehorn containing detailed collec did not discover these records. In 1974, there was at least one attempt to contact Dr Borror to request additional information regarding these collection data, but with no response. This article describes how specimen label tographed, and all specimens cataloged and accessioned MATERIALS AND METHODS The National mosquito collection is comprised of ap proximately 1.5 million specimens and is managed by the focused on gathering specimen data related to ongoing vector-borne disease outbreaks or taxonomic revisions. The Nagasaki specimens were due for accession but had during a routine search for species distribution updates, and the rest of the collection was systematically inspect ed for other specimens collected in post-WWII Japan. tronic museum) data entry form. All specimens were as accessioned into the collection. Although all specimens were assigned new catalog numbers, each record retains every associated original specimen number within the individual records. Each specimen received a unique number and all associated preparations (eg, slides) were also assigned the same catalog number so that all objects associated with each specimen can be tracked using the same catalog number. The 2D matrix barcode labels men. Barcode labels for pinned specimens were added under existing labels and can be read by a barcode scan ner when the specimen is inverted, while barcodes were men labels were photographed to allow verbatim data in interpretation. Specimens were photographed using a Dino-Lite Edge handheld digital microscope (Dino-Lite ity for vertical imaging to document their current condi tion. Each specimen was examined and recorded to doc ument its current condition, sex, and if remounting was required. Figures 1, 2, and 3 show 3 specimen records In order to map these localities, each specimen was geo referenced using the point-radius method 5 which inves tigates text descriptions of localities on specimen labels as well as any information relevant to the description of the collection site provided in original descriptions. entry as possible to serve as a centroid of a collection event. 6 To account for the uncertainty of the exact lo cality, an uncertainty measurement was assigned using the Mammal Networked Information System Georefer encing Calculator (http://maniset.org). 5 This method ac counts for errors and missing information including co ordinate datum, extent of the named place, and precision of the coordinates assigned. All specimen label data that captured and retained. 7 This approach has been applied lection. 8,9 As details about the exact collection sites are not available, specimens within the WWII Japan collec tion were generally assigned a centroid for the city of Nagasaki and an uncertainty measurement encompass ing the entire city. RESULTS A total of 452 specimens representing 16 unique taxa with a summary list of habitat descriptions (bionom ics) reported for each mosquito species are shown in the Table. Although some specimens showed signs of damage, eg, rubbed setae, broken antennae and/or legs, wings, etc, most were in fair shape with labels that could be read clearly. Nearly all specimens in this investiga tion were found to have been collected in Nagasaki, Ja specimens from the 207th MSD were collected in Na gasaki, Kyoto, and Isahaya-shi between 1947 and 1950. vector pathogens, including Plasmodium sp. ( An. sinen sis ), Japanese encephalitis virus ( Ae. togoi Cx. tritae niorhynchus Giles, Cx. vishnui Theobald) and Dengue fever virus ( Ae. albopictus ). In addition, the Table in cludes the vector status for each taxon. CO MM ENT When considering the time and place of these collections, it is natural to wonder whether these specimens show any signs of radiation exposure that can be measured today. However intriguing, it is not likely that these specimens

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10 http://www.cs.amedd.army.mil/amedd_journal.aspx reason is that after the initial explosion over Nagasaki, only low levels of radia tion were recorded from areas outside of 10 Ad ditionally, nuclear fallout is expected to ing on their life history; insects that used than those, such as mosquitoes, that use with rainfall. Fuller et al 11 suggested resil ience of aquatic invertebrate populations to radionuclides. insects after a nuclear explosion are rare, studies examining the impact of radiation exposure due to nuclear reac tor meltdowns may be more appropriate. Williams et al 12 of the Chernobyl nuclear disaster on lo cal populations of Chironomidae species and found morphological deformities in contained nuclear waste was pervasive in Figure 1 Specimen information Catalog Number: USNMENT 01240053 Aedes ( Stg .) albopictus (Skuse, 1894 ) Sex/Lifestage: Female, Adult Preparation: Pin mounted Notes: Specimen is in good condition with diagnostic characters clearly vis ible. Some setae appear rubbed on scutum. Specimen has some dust/de Collection data Locality: Nagasaki, Japan Collection Date: 9 October 1945 Ae albopictus Additional Information: # 8 Figure 2 Specimen Information Catalog Number: USNMENT 01240364 Aedes ( Stg .) albopictus (Skuse, 1894 ) Sex/Lifestage: Whole larva Preparation: Slide mounted Notes: Specimen is in good condition with diagnostic characters clearly visible. Mounting medium appears to be Canada Balsam and has darkened slightly. Collection Data Locality: Iron kettle, bombed area, Nagasaki, Japan Collection Date: 11 October 1945 Ae albopictus Additional Information: # 18C MOSQUITO SURVEILLANCE CONDUCTED BY US MILITARY PERSONNEL IN THE AFTERMATH OF THE NUCLEAR EXPLOSION AT NAGASAKI, JAPAN, 1945

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January June 2018 11 ecosystem for years after the disaster. A study investigating the possible im pact of the Fukushima Dai-ichi Nuclear Power Plant meltdown of 2011 on local populations of the pale grass blue butter Zizeeria maha ) found some evidence of morphological abnormalities attribut ed to radiation exposure. 13 However, this site also had persistent radiation expo sure risk. Biological asymmetry, known used as a measure of developmental sta bility. A stud y 14 on stag beetles ( Lucanus cervus ) in Chernobyl found that males cantly elevated levels of FA in second ary sexual characters compared to males from control sites. A detailed study of FA in mosquito samples from Nagasaki may radiation but data on mating success are no longer possible. The specimens examined during this study represent a lasting and permanent record for the invaluable work done to borne disease threats during the Allied forces occupation of Japan. Military en during that time made systematic col for vector species to inform mosquito abatements plans. Although it has been nearly 75 years since these collections were made, the specimens form a lasting legacy that can be used in taxonomic re visions and to accurately predict species distributions and biology. ACKNOWLEDGE M ENTS This study was made possible by a FY2017 grant (P0091_17_WR_1.3.1.) from the Armed Forces Health Surveillance Branch and its Global Emerging Infections Surveillance Section. This research was performed under a Memorandum of of Research and the Smithsonian Institutions National Museum of Natural History, with institutional support REFERENCES 1. La Casse WJ. Mosquito Survey Data on Japan and Their Application in the Control of MosquitoBorne Diseases 2. Gray HF. Mosquito control problems in Japan. Mosq News 1947;7(1):7-11. 3. the adult and larval mosquitoes of Japan (including and Korea (Diptera: Culicidae). Contrib Am Ento mol Inst 1979;16. Figure 3 Specimen information Catalog Number: USNMENT 01240280 Culex ( Ocu .) bitaeniorhynchus (Giles, 1901 ) Sex/Lifestage: Male, Adult Preparation: Pin mounted adult with slide mounted genitalia Notes: Specimen is in fair condition with diagnostic characters clearly visible. be Euparal and remains clear. Collection data Locality: Nagasaki, Japan Collector: Borror, D.J. Collection Date: 15 November 1945 Culex ( Culex ) bitaeniorhynchus 1973 Additional Information: SEAMP ACC No. PREP 69/1396 ; #1 E

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12 http://www.cs.amedd.army.mil/amedd_journal.aspx 4. Gaunt SL. In memoriam: Donald J. Borror. The Auk. 1989;106:321-323. Available at: https://sora. p0321-p0323.pdf. Accessed July 9, 2018. 5. method for georeferencing locality descriptions and calculating associated uncertainty. Int J Geogr Inf Sci 2004;18(8):745-767. 6. GeoNames Website. Available from: http://www. geonames.org/. Accessed March 2018. 7. Foley DH, Wilkerson RC, LM Rueda. Importance of the what, when, and where of mosquito col lection events. J Med Entomol 2009;46(4):717-722. 8. and distribution of New World Phlebotomine sand Flies (Psychodidae: Diptera), with special empha sis on primary types and species diversity. US Army Med Dep J. July-September 2015:33-46. 9. Bousses P, Debboun M. New records, distribution, and updated checklists of old world Phlebotomine Asia, and Central Asia. US Army Med Dep J. Janu ary-June 2017:65-85. 10. World Nuclear Association. Hiroshima, Nagasaki, ed March 2016. Available at: http://www.world-nu clear.org/information-library/safety-and-security/ radiation-and-health/hiroshima,-nagasaki,-andsubsequent-weapons-testin.aspx Accessed March 2018. 11. Fuller N, Smith JT, Nagorskaya GL. Does Cher nobyl-derived radiation impact the developmental stability of Asellus aquaticus 30 years on?. Sci To tal Environ 2017;576:242-250. A summary of the mosquito specimens considered within this study. Species names are presented along with the total number of specimens associated with each taxon, each species vector status and the collection site description used to inform species Species Name Specimen Count Vector Status Collection Site Description Aedes ( Hul .) japonicus (Theobald, 1901 ) 13 WNV Fire tub, cemetery urn, rock hole Aedes ( Stg .) albopictus (Skuse, 1894 ) 127 DENV, CHIKV, ZIKV Bamboo stump, bamboo vase, concrete tub, creek, pan, iron kettle bombed area, cemetery urn, wooden tub Aedes ( Tan .) togoi (Theobald, 1907 ) 149 JEV Bamboo stump, bucket, cement tank, ditch, fire tub, rock hole, tank in bombed area, wooden barrel Anopheles ( Ano .) koreicus Yamada and Watanabe, 1918 15 Cement tank, seepage pool Anopheles ( Ano .) sinensis s.l. 31 Brugia malayi and secondary vector of Plasmodium sp. Ditch, grassy pool, nightsoil pool, pond, rice paddy Armigeres ( Arm .) subalbatus (Coquillett, 1898 ) 22 Wuchereria bancrofti Crack, nightsoil pool Culex ( Cui .) pallidothorax Theobald, 1905 21 Cave pool, creek in bombed area Culex ( Cux .) quinquefasciatus Say, 1823 6 Wuchereria bancrofti Concrete tank, stone pool Culex ( Cux .) tritaeniorhynchus Giles, 1901 23 JEV Cement tank, fire tub, nightsoil pool, pond, rice paddy Culex ( Cux .) vagans Wiedemann, 1828 7 No data Culex ( Cux .) vishnui Theobald, 1901 1 JEV Artificial pond Culex ( Eum .) hayashi Yamada, 1917 14 Air raid shelter, cement tank, lily pond, ground pool Culex ( Lop .) infantulus Edwards, 1922 9 Cave pool Culex ( Ocu .) bitaeniorhynchus Giles, 1901 5 No data Tripteroides ( Trp .) bambusa (Yamada, 1917 ) 8 Bamboo stump Uranotaenia ( Ura. ) bimaculiala (Leicester, 1908 ) 1 No data WNV indicates West Nile virus; DENV, Dengue virus; CHIKV, chikungunya virus; ZIKV, Zika virus; JEV, Japanese encephalitis virus. MOSQUITO SURVEILLANCE CONDUCTED BY US MILITARY PERSONNEL IN THE AFTERMATH OF THE NUCLEAR EXPLOSION AT NAGASAKI, JAPAN, 1945

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January June 2018 13 12. in Belarusian chironomids (Diptera: Chironomi dae) subsequent to the Chernobyl nuclear disaster. Freshw Biol 2001; 46(4):503-512. Available at: https://onlinelibrary.wiley.com/doi/full/10.1046/ j.1365-2427.2001.00699.x. Accessed July 9, 2018. 13. Hiyama A, Nohara C, Kinjo S, Taira W, Gima S, The biological impacts of the Fukushima nuclear accident on the pale Sci Rep 2012; 2(570). Avail able at: http://www.nature.com/articles/srep00570. Accessed July 9, 2018. 14. Mller AP. Developmental instability and sexual selection in stag beetles from Chernobyl and a con trol area. Ethology 2002;108:193-204. Available at: https://doi.org/10.1046/j.1439-0310.2002.00758.x. Accessed July 9, 2018. AUTHORS Mr Pecor is a Research Technician with the Walter Reed Army Institute of Research, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland. Dr Foley is a Research Entomologist at the Walter Reed Army Institute of Research, and a Research Associate of the Entomology Department within the National Mu seum of Natural History, located at the Smithsonian In stitution, Museum Support Center, Suitland, Maryland. He completed a Walter Reed Army Institute of Research

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14 http://www.cs.amedd.army.mil/amedd_journal.aspx Georgias exposure to emerging mosquito-borne dis eases is increasing due to international travel, immigra tion to Georgia, and out of state residents relocating to Georgia. The Department of Public Health (DPH) main tained its mission to prevent and respond to Zika virus (ZIKV) transmission and used its current funding to prepare for future public health emergencies. The prevention or reduction of transmission of mosqui to-borne diseases is completely dependent on the con trol of mosquito vectors and limiting person-mosquito contact. Mosquito surveillance is a key component of any local integrated vector management program. The man risk by determining local vector presence and abundance. Historically, the DPH was tasked with deal ing with nuisance mosquito complaints with limited funding for mosquito control, not to mention mosquito surveillance. Not until the introduction of West Nile vi begin dealing with mosquito vector species. several years and most mosquito control programs were ties in Georgia conducted sporadic mosquito surveil lance, and by 2015, the number of counties was reduced to 13. Further, the availability of known mosquito con trol was limited to 6 counties. However, with the dec the ZIKV threat constituted a public health emergency, funding was provided to increase mosquito surveillance and emergency mosquito control. 1 INTEGRATED MOSQUITO MANAGE M ENT Mosquito control is integral to protect the public health. preference, larval habitat, and potential for carrying and transmitting infectious diseases. Although nuisance mosquitoes can already be consid ered a health problem in Georgia, mosquitoes that carry infectious diseases like WNV, La Crosse encephalitis (LAC), and eastern equine encephalitis (EEE), as well as those that can transmit new and emerging viruses such as chikungunya and ZIKV are especially consid ered a public health concern. Georgias Collaborative Approach to Expanding Mosquito Surveillance in Response to Zika Virus: Year Two Thuy-Vi Nguyen, PhD, MPH Rosmarie Kelly, PhD, MPH Shawna Stuck, MPH R. Christopher Rustin, DrPH, MT, REHS ABSTRACT With the continued increase in international travel and immigration to Georgia, the Department of Public Health (DPH) continued its mission to prevent and respond to Zika virus (ZIKV) transmission. Methods: conducting surveillance, total number, and overall percentage of mosquito species collected in 2016 and 2017. Mosquito surveillance in 2017 was mapped by county and species using ArcMap 10.2.0. Results: From 2016 and 2017, mosquito surveillance increased from 60 to 159 counties (165% increase). A total not collected in 2017, while other species found in 2017 were not previously collected during mosquito surveil lance. Also, certain mosquito species were found outside of their expected geographical range. Conclusion: The continued collaborative response to ZIKV by the DPH allowed a continued increase in its sur veillance program. Existing and new partnerships continued to develop with military and local health depart ments to expand and share data. This additional surveillance data allowed DPH to make sound public health decisions regarding mosquito-borne disease risks and close gaps in data related to vector distribution.

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January June 2018 15 the nuisance factor and protect public health is the use of a wide variety of control methods known as Integrated species, and location of mosquitoes. THE IM PORTANCE OF MOSQUITO SURVEILLANCE bone of every mosquito control operation. Surveillance for native and exotic mosquito species should be part of mosquito control, regardless of the immediate threat of disease outbreaks. It should be developed proactively to justify mosquito control funding requirements and risk for arboviral disease transmission. The primary purpose of mosquito surveillance is to de termine the species composition, abundance, and spa tial distribution within the geographic area of interest through collection of eggs, larvae, and adult mosquitoes. Surveillance is valuable for determining changes in the geographic distribution and abundance of mosquito spe lance and postsurveillance data, obtaining relative mea surements of the vector populations over time, accumu lating a historical database, pesticide resistance studies, and facilitating appropriate and timely decisions regard ing interventions. METHODS Mosquito surveillance trapping data provided by the DPH and that collect ed in collaboration with DPH were an of counties conducting surveillance, total number, and overall percentage of mosquito species collected in 2016 were compared to 2017 data. Mosqui to surveillance in 2017 was mapped by county and species using ArcMap 10.2.0 (Esri, Inc, Redlands, CA). Hu man and livestock case data were also compared to surveillance data to de tect disease patterns. RESULTS In 2017, mosquito surveillance was performed in all 159 Georgia coun ties (Figure 1). This is compared to surveillance conducted in 60 coun ties in 2016, and only 13 counties in surveillance data was collected in every county in Georgia, and while surveillance was limited in many counties, these data can serve as an initial baseline. The focus of mosquito surveillance has traditionally been on WNV, LAC, and EEE vectors, thus data reported to the DPH from other sources is incom vectors sent for arboviral testing. Sim ilar to previous years, including 2016, Culex quinquefasciatus (Say) was captured at the highest percentage of mosquitoes collected overall in 2017 (62.5%/56%) (Table 2). Trapping was eas to target container-breeding Ae des aegypti (L.) and Ae. albopictus (Skuse), and the shift in surveillance focus was demonstrated in the grad ual increase in Ae. albopictus (3.7% to 4.0%) from 2016 to 2017 (Table 2). Although the restriction of limited sur veillance was not a problem in 2017 with surveillance being performed in all counties in Georgia, Ae. aegypti was found only in Muscogee County, March January February April May June July August September November December October 40 Miles 0 N Figure 1 The month in which mosquito surveillance was per formed in each county in 2017 Surveillance was performed during several months in some counties. Table 1 Number and percentage of counties with mosquito surveillance performed per year, 2001-2017 Year No. of Counties Conducting Surveillance Percentage of Counties (N=159) 2001 2 1.3% 2002 11 6.9% 2003 26 16.4% 2004 56 35.2% 2005 55 34.6% 2006 28 17.6% 2007 28 17.6% 2008 28 17.6% 2009 26 16.4% 2010 22 13.8% 2011 19 11.9% 2012 12 7.5% 2013 13 8.2% 2014 15 9.4% 2015 13 8.2% 2016 60 37.7% 2017 159 100.0%

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16 http://www.cs.amedd.army.mil/amedd_journal.aspx Table 2 Mosquito species collected per year, 2015-2017 Species 2015 Totals from 13 Counties Percentage of Total Collection from 13 Counties 2016 Totals from 60 Counties Percentage of Total Collection from 60 Counties 2017 Totals from 159 Counties Percentage of Total Collection from 159 Counties Ae. aegypti 82 0.108% 26 0.018% 32 0.021% Ae. albopictus 1,141 1.500% 5375 3.698% 6,175 4.047% Ae. cinereus 0 0.000% 4 0.003% 143 0.094% Ae. vexans 162 0.213% 6,583 4.529% 3,295 2.159% Aedes/Ochlerotatus spp. 6 0.008% 120 0.083% 243 0.159% An. barberi 0 0.000% 1 0.001% 0 0.000% An. crucians 25 0.033% 1,879 1.293% 1,230 0.806% An. punctipennis 26 0.034% 494 0.340% 1,100 0.721% An. quadrimaculatus 61 0.080% 268 0.184% 74 0.048% Anopheles spp. 5 0.007% 135 0.093% 214 0.140% Cq. perturbans 1,265 1.663% 5,975 4.111% 1,820 1.193% Cs. inornata 130 0.171% 14 0.010% 12 0.008% Cs. melanura 906 1.191% 996 0.688% 2,139 1.402% Culex spp. 4,996 6.569% 10,876 7.483% 9,401 6.161% Culiseta spp. 0 0.000% 0 0.000% 12 0.008% Cx. coronator 262 0.345% 629 0.433% 542 0.355% Cx. erraticus 300 0.394% 2,425 1.676% 2,211 1.449% Cx. nigripalpus 5,657 7.438% 11,101 7.638% 26,599 17.431% Cx. peccator 0 0.000% 12 0.008% 0 0.000% Cx. quinquefasciatus 60,423 79.450% 90,709 62.409% 85,357 55.938% Cx. restuans 100 0.131% 389 0.268% 460 0.301% Cx. salinarius 350 0.460% 2,962 2.038% 7,954 5.213% Cx. territans 1 0.001% 34 0.023% 70 0.046% Ma. dyari 0 0.000% 0 0.000% 3 0.002% Ma. titillans 0 0.000% 98 0.068% 244 0.160% Oc. atlanticus 1 0.001% 758 0.522% 298 0.195% Oc. canadensis 0 0.000% 117 0.081% 1 0.001% Oc. fulvus pallens 0 0.000% 1 0.001% 39 0.026% Oc. infirmatus 2 0.003% 45 0.031% 74 0.048% Oc. japonicus 8 0.011% 53 0.037% 376 0.246% Oc. mitchellae 0 0.000% 9 0.006% 8 0.005% Oc. sollicitans 0 0.000% 0 0.000% 30 0.020% Oc. sticticus 0 0.000% 31 0.021% 36 0.024% Oc. taeniorhynchus 0 0.000% 5 0.003% 488 0.320% Oc. thibaulti 0 0.000% 0 0.000% 2 0.001% Oc. triseriatus 25 0.033% 71 0.049% 74 0.048% Oc. trivittatus 0 0.000% 7 0.005% 499 0.327% Or. signifera 3 0.004% 23 0.016% 117 0.077% Ps. ciliata 0 0.000% 25 0.017% 46 0.030% Ps. columbiae 88 0.116% 332 0.229% 225 0.147% Ps. cyanescens 2 0.003% 30 0.021% 100 0.066% Ps. discolor 0 0.000% 0 0.000% 5 0.003% Ps. ferox 10 0.013% 106 0.073% 326 0.214% Ps. howardii 3 0.004% 34 0.023% 9 0.006% Ps. mathesoni 0 0.000% 0 0.000% 9 0.006% Psorophora spp. 6 0.008% 0 0.000% 9 0.006% Tx. rutilus 1 0.001% 52 0.036% 21 0.014% Ur. iowii 0 0.000% 13 0.009% 2 0.001% Ur. sapphirina 2 0.003% 118 0.081% 43 0.028% unknown 3 0.004% 2,411 1.659% 426 0.279% Total 76,052 145,346 152,593 GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCE IN RESPONSE TO ZIKA VIRUS: YEAR TWO

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January June 2018 17 again at low numbers (n=32) similar to 2016 (n=26) (Ta ble 2). The statewide results suggest that Ae. albopictus has outcompeted this species, an occurrence reported previously in current literature. 2 We continue to explore why this small pocket of Ae. aegypti persists in Musco gee County. The expected continuing increase of ZIKV throughout travel-associated case of ZIKV was reported in Georgia in December 2015. In 2016, there were 113 travel-associ ated cases reported in Georgia. In 2017, there were a to tal of 6 travel-associated cases. To date, there have been no locally transmitted (mosquito to human) cases of Zika in Georgia. For travel-associated cases, a response protocol was developed and followed where vector sur veillance coordinators (VSC) performed adult mosquito surveillance around the residence of each case, as well as applying larvicide once mosquito breeding sites were formed if the residence was in a high risk area. West Nile Virus The WNV is a mosquito-borne disease of birds. Humans are occasionally infected with WNV through mosquito bites. Approximately, 1 in 5 people infected with WNV develop symptoms of West Nile fever, often charac weakness. 3 Less than 1% of people infected with WNV develop neurologic disease such as meningitis, encepha 3 umented in Georgia in July 2001. Six human cases of WNV encephalitis were reported in Georgia that year, including one death. Cases have been reported each year since, with varying numbers of human deaths. To im surveillance for WNV illness in humans was expanded for the 2003 transmission season to include all acute in fections of WNV. In addition, routine screening of the national blood supply began in 2003, resulting in the to the development of symptoms (some WNV infec tions are asymptomatic). While the majority of human infections with arboviruses have resulted from bites by infected mosquitoes, other rare modes of transmission organ transplantation. The increase in WNV among mosquitoes, humans, and birds represents the impor tance of mosquito surveillance to monitor disease pat terns, facilitating rapid response to disease outbreaks. Figure 2 The number of counties conducting annual mosquito surveillance, 2001-2017 ; the number of counties detecting WNV each year; the percentage of the annual collection testing positive for WNV. Note: *indicates 6 counties conducted testing; **indicates 5 counties conducted testing. % WNV Positive Number of Counties 10 40 0 50 30 60 80 20 70 90 150 160 170 140 130 120 110 100 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 *2013 *2014 *2015 *2016 **2017 7% 6% 5% 4% 3% 2% 1% 0% Counties with Positive WNV Results Counties Performing Surveillance % of Collection WNV Positive

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18 http://www.cs.amedd.army.mil/amedd_journal.aspx cantly, making it the states second most active year after 2012. Georgia reported 48 cases of WNV and 15 WNV presumptive viremic blood donors (PVD), with 7 deaths in 2017. The PVDs were asymptomatic at the time of blood donation, but tested positive for the pres ence of select arboviruses. Forty-three (87.5%) of the 48 cases experienced WNV neurologic illness (altered mental status, paralysis, en and 5 (10.4%) were diagnosed with WNV fever. The average age of the 48 case population was 61.4 years (range 17-87). The average age of those with WNV neu rologic illness (n=5) was 64.6 years (range 26-87). Forty (83%) of the 48 cases were male. The majority of cases were reported in July, August, and September, with the peak in August. California serogroup (CS) viruses, including California encephalitis, Keystone, La Crosse encephalitis (LAC), Jamestown Canyon, snowshoe hare, and trivittatus, are States, LAC is the most common of the California sero group viruses. There were 2 cases of LAC reported in were reported in Georgia, compared to one case of EEE in 2016. Invasive Mosquito Species mining where mosquito species are found, as well as monitoring a change in species range. This is especially important for vector species and for invasive species, which may become involved in arboviral disease cycles. Culex coronator Georgia in 2006. It was found initially in counties below the Fall line (Figure 3), a geological boundary dividing Georgias Coastal Plain from its Piedmont region. 4 Mos quito surveillance conducted in 2017 showed that this species can now be found in most regions of Georgia (Figure 4). It is important to monitor Cx. coronator as it has the potential to be involved in the WNV transmis sion cycle. Ochlerotatus japonicus in Georgia in 2002. Since this species lays its eggs in rock pools, it was initially found only above the Fall line (Figure 5). Mosquito surveillance conducted in 2017 showed that this species can now be found in most re gions of Georgia (Figure 6). Similar to Cx. coronator it Figure 4 Counties where specimens of Culex coronator spe cies were collected in 2017 No Data Less than 10 More than 10 Count of Culex coronator species collected in 2017 40 Miles 0 N Figure 3 Counties where specimens of Culex coronator spe cies were collected in 2009 Counties Culex coronator 2009 40 Miles 0 N GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCE IN RESPONSE TO ZIKA VIRUS: YEAR TWO

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January June 2018 19 is important to monitor Oc. japonicus because it also has the potential to be involved in the WNV transmis sion cycle. Comprehensive statewide surveillance allowed DPH to observe the geographic distribution of these important to areas of the state where they had not been found before. CO MM ENT Resources and Preparedness Prior to 1970, adequate infrastructure, funding, and yellow fever, dengue, and malaria were generally avail able. However, once these diseases were eradicated in decreased the resources for surveillance, prevention, and control of vector-borne diseases. This was under standable because control programs had reduced the public health threat from these diseases, thus lowering the priority for allocation of resources. Those decisions, notwithstanding the technical problems of insecticide, drug resistance, and excessive emphasis on insecticide sprays to kill adult mosquitoes, contributed greatly to the resurgence of diseases such as malaria and dengue, and the introduction and rapid spread of diseases such as WNV. Decreased resources for vector-borne diseases in general resulted in the discontinuation or merger of many programs, and ultimately to the deterioration of the public health infrastructure necessary to deal with those diseases. Moreover, training programs in vectorborne diseases decreased dramatically after 1970. Thus, the DPH was faced with a critical shortage of special vector-borne diseases, such as Zika virus. The likely consequence to Georgia of a continued lack of good vector surveillance and control programs is the knowledge gap as to which mosquitoes and which dis ability to provide accurate information regarding risk of disease, the detection of new arboviruses that were be ing introduced to Georgia, and which new diseases were competently vectored would also be of great concern. Since arboviral pathogens could not be detected early, before they infected humans, Georgia experienced cases of arboviral disease that could have been prevented, and, because some of those pathogens are singularly lethal, the state also experienced unnecessary morbidity and additional Zika funding from the Centers for Disease Control and Prevention (CDC), began building a team of to the threat of Zika virus. Counties Ochlerotatus japonicus 2009 40 Miles 0 N Figure 5 Counties where specimens of Ochlerotatus japoni cus species were collected in 2009 Figure 6 Counties where specimens of Ochlerotatus japoni cus species were collected in 2017 No Data Less than 100 10-100 More than 100 Count of Ochlerotatus Japonicus species collected in 2017 N 40 Miles 0

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20 http://www.cs.amedd.army.mil/amedd_journal.aspx Vector Surveillance Coordinator Districts The establishment of 4 regional VSC districts has begun to rebuild Georgias capacity to detect and respond to both existing and newly introduced vector-borne diseas es. The vector-borne disease prevention program from 2016 has been strengthened with the hiring of additional mosquito surveillance in more counties around the state. Nine of 18 health districts were assigned a VSC, whose responsibility is to conduct and improve mosquito sur veillance for arborviral diseases such as WNV, EEE, LAC, Zika and other mosquito-borne diseases. Due to limited funding, not all health districts were assigned a VSC to assist with mosquito surveillance; these districts were assigned to the state entomologists. However, some of the districts already had mosquito surveillance pro grams, and some had an environmental health director or environmental health specialists (EHSs) who had an interest in conducting mosquito surveillance within their district or county, and a sound collaboration was formed. The VSCs were placed in areas of potential higher risk and regions with little to no mosquito control in most of the included counties to provide more thorough surveil lance in the designated districts. Additional and more comprehensive training was provided to the VSCs to strengthen their knowledge based on both larval and The DPH established a goal for the 2017 mosquito season to conduct surveillance in all 159 counties. Surveillance started in May 2017, and together with EHSs and mos quito control, surveillance was conducted in every coun ty in Georgia, accomplishing our goal. To better prepare surveillance equipment and training in mosquito sur interested people in every health district. In response to the threat of possible Zika transmission, the DPH set up 10 additional trailers (total of 11) with mosquito-borne disease threat response equipment, a moveable labora and emergency control supplies and equipment. The Future Any vector control should be guided by robust mosquito tions. Surveys performed by the CDC found an increase Ae. aegypti and Ae. albopictus mitting vectors. 5 reporting the presence of Ae. aegypti and Ae. albopictus as compared to a previous report. 5 This demonstrates a continued risk of mosquito-borne diseases and the im portance of statewide surveillance. CONCLUSION The small increase in overall mosquito prevalence in 2017 could be due to low numbers in rural areas where breeding sites for anthropophilic mosquito species are not as prevalent. The data support the decisions made for previous mosquito surveillance programs where sur veillance was only performed in high risk suburban ar eas when limited funding was provided. In Georgia, statewide mosquito surveillance was con ducted in all 159 counties in 2017. The goal of vector control was to suppress Ae. aegypti and Ae. albopictus manner to prevent or interrupt Zika virus transmission. The CDC developed guidelines on their surveillance tivities used in a vector control response depends on the extent of mosquito-borne transmission, as measured by the number of Zika cases and their geographic and tem poral distribution. The increase in Zika vector species collected in 2017 compared to previous years represents the progress and success of rebuilding the vector sur veillance program in Georgia. REFERENCES 1. plications [internet]. 2017. Available at: http://www. ruary 2, 2017. 2. Champion SR, Vitek CJ. Aedes aegypti and Aedes albopictus EHI 2014;8(suppl 2):35-42. 3. Centers for Disease Control and Prevention. West Nile virus [internet]. 2018. Available at: https:// www.cdc.gov/westnile/index.html. Accessed March 14, 2018. 4. Duncan MS. Fall Line. New Georgia Encyclopedia [internet]. 2016. Available at: http://www.georgia encyclopedia.org/articles/geography-environment/ fall-line. Accessed February 22, 2018. 5. Hahn MB, Eisen L, McAllister J, Savage HM, (Stegomyia) aegypti and Aedes (Stegomyia) al 1995-2016. J Med Entomol 2017;54(5):1420-1424. GEORGIAS COLLABORATIVE APPROACH TO EXPANDING MOSQUITO SURVEILLANCE IN RESPONSE TO ZIKA VIRUS: YEAR TWO

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January June 2018 21 AUTHORS Dr Nguyen is a Public Health Entomologist with the Vector-Borne & Zoonotic Diseases Team, Environmen tal Health Section, Georgia Department of Public Health, Atlanta, Georgia. Dr Kelly is a Public Health Entomologist with the Vec tor-Borne & Zoonotic Diseases Team, Environmental Health Section, Georgia Department of Public Health, Atlanta, Georgia. Ms Stuck is a Vectorborne Disease Epidemiologist with the Acute Disease Epidemiology Section, Georgia De partment of Public Health, Atlanta, Georgia. Dr Rustin is the Director of Environmetal Health and Deputy Director of the Division of Health Protection, Georgia Department of Public Health, Atlanta, Georgia. Borden Institute Invites New Publication Ideas of Excellence, invites the submission of topics for publication. All subjects and perspectives associated with the art and science of military medicine are welcome. This includes textbooks, monographs, specialty books, and history publications. This call for submissions is open from August 10, 2018, through November 10, 2018. Although the Borden Institute has numerous book projects in production, we encourage the submission of new topics for future publication consideration. Please see our website, www.cs.amedd.army.mil/borden, for information about the Borden Institute, a complete publication list, and author guidelines. Publication proposals should be 3 to 10 pages in length and include the following information: 1. Your complete contact information: name, address, e-mail address, telephone number, and fax numbers; also clearly indicate the corresponding author or editor if there is more than one associated with the proposal. 2. Title of proposed book. 3. Proposed table of contents. 4. Main topic of book. 6. Timeline for completion of the manuscript. series? How does your book uniquely contribute to military medicine? Submissions will be reviewed by the Borden Institute Publication Board and all potential authors and editors will Send proposals to: Borden Institute 3630 Stanley Rd. Bldg. 2841, Rm. 1326 Please feel free to contact the Borden Institute with questions or for further help with the submission process: 210-221-0760; http://www. cs.amedd.army.mil/borden.

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22 http://www.cs.amedd.army.mil/amedd_journal.aspx Aedes vectored viruses such as chikungunya (CHIKV), dengue (DENV), yellow fever (YFV), and Zika (ZIKV) should not be underestimated. A recent study 1 found active-duty travelers and those visiting friends and the Americas had a composite attack rate for CHIKV, and DENV infection of 3.7%. The authors point out the risk of returning travelers with subclinical infections causing secondary transmissions in nonendemic re pretravel counseling to ZIKV-outbreak regions due to the shared vector, Aedes aegypti (L.) of CHIKV, DENV, YFV and ZIKV. Although Ae. albopictus (Skuse) is thought to be a competent vector of ZIKV, 2 Ae. aegypti has been implicated as the primary transmitter of the virus in human populations in the recent outbreak in the Americas. 3,4 laration of a public health emergency of international concern over ZIKV linked disease, the Walter Reed tormap.si.edu/Project_ESWG_ExcelZika.htm) that use published average yearly habitat suitability models and average monthly temperature data to predict the timing of Aedes 5 Excel-based tools were constructed to assist entomologists and other health personnel understand whether ZIKV transmission is likely to occur at a location and when they should con duct vector surveillance and control. Foley and Pecor 5 the approach could be used with any habitat suitability models and for any area of interest. The ability to in corporate near real-time and forecast temperature data improved accuracy in the short term compared to the use of average monthly temperature data, which were more suited for longer term planning. For tropical areas compared to temperate ones, tempera ture is less dominant among climatic drivers of intraannual changes in mosquito suitability, which limits the applicability of the approach of Foley and Pecor 5 for of recently published global monthly habitat suitability models for Ae. aegypti and Ae. albopictus 6 presents an opportunity to extend to new areas our approach for Bugoch et al 6 used monthly climatic suitability models for autochthonous transmission of ZIKV around the world, conditional on the predicted occurrence of com petent Aedes mosquito vectors. To account for seasonal variation in the geographical range of ZIKV suitability, they produced maps for each month of the year. They used mosquito species distribution models for Ae. ae gypti and Ae. albopictus 7 data and covariates) to make monthly predictions by use of new monthly covariates for temperature-persistence An Excel Spreadsheet Tool for Exploring the Seasonality of Aedes Vector Hazard for User-Specified Administrative Regions of Brazil Desmond H. Foley, PhD David B. Pecor, BS ABSTRACT Aedes -vectored viruses are a major concern for active-duty military personnel working in South and Central America at certain times of the year. Knowledge about the seasonal changes of vector activity is important as it informs time-sensitive vector control, prophylaxis, and travel decisions. To assist in-country and extralim spreadsheet tool that uses published monthly habitat suitability models to display various aspects of average Aedes suitability models into user-friendly formats to provide actionable intelligence for areas of interest.

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January June 2018 23 suitability, 8 relative humidity, and precipitation. They that the sum of all monthly maps equaled the annual mean map of Kraemer et al. 9 Final global monthly vec tor maps show predictions of areas with high likelihood for observation or detection of mosquito populations, able transmission of vector-borne diseases to humans. The extended Figure 6 in the article by Faria et al 10 shows the 12-monthly suitability maps for ZIKV trans mission of Bugoch et al 6 for the Americas. Faria et al 10 region, there was a strong association between estimat (adjusted R 2 >0.84, P <.001). They also found that, sim time lag was evident. In this article, we demonstrate the potential utility of global monthly habitat suitability models to explore Ae des ing on our experience with the Excel user interface de tool that shows the intensity of Aedes point throughout the year. MATERIALS AND METHODS Twelve monthly raster layers of 0.04166665 degrees resolution were obtained for Ae. aegypti habitat suitability. 6,9,10 We used the Global Administrative Areas (GADM) v 2.8* Administrative regions 2nd order administrative was necessary before use. Some names were used mul Map 10.4 (Environmental Systems Research Institute, Redmond, CA) that concatenated Admin 1 (State) and 2 (District) so that each row in the feature table had a unique name combination. 8 were outlying islands (Esprito Santo_Ilha Trindade, pletely overlapped the raster coverage (Bahia_Madre de do Norte_Fernando de Noronha, Rio Grande do Sul_ Capela de Santana, Santa Catarina_Floriniapolis, So These were not considered further in the analysis. Santa Catarina_Florianpolis, which is comprised of a peninsula and nearby island are present in GADM as 2 polygons; the island (Florianopolis) and spelling]). We created a point layer from the polygon layer by us ing Data Management Tools>Features>Feature to Point tool and added longitude and latitude to the points leted. However, for the population analysis (LandScan) involved the need to aggregate some polygons and cor rect the names of several others. Extraction of all ad ministrative area centroid raster values (ie, average statistics as Table tool and, where needed, the Extract values to points tool. This approach was needed because smaller polygons would not produce results using the Zonal statistics as Table tool, which necessitated using the raster data associated with the points for these fa cilities administrative areas. We used the human popu lation density according to LandScan 2011. This was accomplished using the summary output in the Zonal Statistics as Table tools in ArcMap. Seasonality: Ranking Seasonality can be presented as a graph of the 12-month pattern of habitat suitability, abundance, etc. Interpreta tion and comparison of the pattern in one area to other areas can be subject to human error, due to variation in the y-axis, which may mask the underlying pattern. For this reason, we explored the use of rank and related sites that exhibit a seasonal pattern in Ae. aegypti habi ing (1 to 12) in Excel (RANK.EQ) to allow comparison within and among areas of interest, both in terms of the relative suitability and the direction (rise=1, fall= 1) of change in suitability with the next time period. Ideally, metrics automatically derived from the rank should in form the user that for the month in question, suitability scores are near the annual peak or lowest point, scores are set to increase or decrease, or scores are moving in http://www.gadm.org/ LandScan 2011 People/ 1 sq km. This product was made using the LandScan ( 2011 ) High Resolution Global Population Data Set, the copyright to which is held by UT-Battelle, LLC, which oper ates the Oak Ridge National Laboratory under contract to the US Department of Energy. The US Government has certain rights in the data set. Neither UT-Battelle, LLC, nor the US Department of Energy, nor any of their employees, makes any warranty, express or implied, or assumes any legal liability or responsibility for the accuracy, completeness, or usefulness of the data set. Informa tion about LandScan is available from the Oak Ridge National Laboratory at: http://www.ornl.gov/sci/landscan/.

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24 http://www.cs.amedd.army.mil/amedd_journal.aspx a certain direction. Scores derived for one location can readily be contrasted with those from another. Average habitat suitability values were calculated for 2 (2 weeks) that were ranked (1 to 24). In addition to rank (1 to 24) and rise/fall (1, 1), we constructed metrics that measured accumulated rise/fall values, to show the dura tion of the rise and fall extending into the future (future trend or forecast) and the past (past trend or hind cast). We scored a rise as 1 and a no rise as 1, and considered that if change in rank was unidirectional, the rise/fall value would be the same as the preceding rise/fall value. Instances where a plateau or trough was present can be disguised by the ranking process, due to the exaggera round up suitability values to three decimal places to tie the ranks of similar scores. Equal Rank ascending in Excel sometimes resulted in the maximum being less than 24 due to tied ranks. To address this, we calculated the maximum rank in a separate column and changed aggerating the jump in rank to the maximum of 24 in sonal pattern of rank values with 6 important points in a typical seasonal cycle and the output for various metrics. Seasonality: Multivariate Analysis ated Interpolated surfaces (Spatial Analyst Tools>Interpolation>Kriging) for the rank of each second order administrative area, and then cre ated a mask around each point of 100 km (Analysis together. Then we clipped interpolated surfaces by the mask (Spatial Analyst Tools>Extraction>Extract by Mask), and created a 3-band (red, green, blue) principle faces to give a summary of the yearly seasonal pattern (Spatial Analyst Tools>Multivariate>Principle Compo nents). We also developed iso clusters (Spatial Analyst cation) based on 2 and 6 classes for the 12 interpolated clusters on the original 12 monthly habitat suitability models. The overlay map show the 5 regions described in Faria et al, 10 the outlines of the states, and the colorcoded Aedes capabilities are discussed further in the Seasonality Graphics Presentations section on page 25. RESULTS An Excel tool was constructed (Figure 2) with the fol lowing components: User Controlled Inputs These comprise drop-down lists and dependent dropdown lists: Select State Select District Select Date Automatically Generated Values Aedes hazard this date: The more red that extends to the right, the higher the Aedes indicate the probability of mosquito occurrence (0 1.0). Annual Aedes hazard this place: The more red that ex tends to the right, the higher the Aedes location across the whole year. Bars indicate the prob ability of mosquito occurrence (0 1.0). Rank this date (1 low, 24 high) : The rank from the low est Ae. aegypti probability (=1) to the highest (=24) for each of 24 two-week periods for the particular location selected. Maximum rank this location: The maximum rank over 24 two-week periods for the particular location selected. Note that maximum rank can be less than 24 due to tied scores. Future trend (rising 1 falling -1 ) : Is the Ae. aegypti probability going to rise (1) or fall ( 1) in the next 2-week period? Stationary values do not change the prevailing score. Past trend (hind cast): Ascending number of consecu tive times that the probability of Ae. aegypti has risen (positive) or fallen (negative) as time advances, eg, 12 means that the following period will be the 12th succes sive time that values have increased, and -2 means that the following period will be the second successive time counted as a continuation of the prevailing trend. Future trend (forecast): Descending number of consec utive times that the probability of Ae. aegypti is predict ed to rise (positive) or fall (negative) as time advances, eg, 1 means that 1 successive period of rising values is predicted to occur, 12 means that 12 successive periods EXCEL TOOL FOR AEDES VECTOR SEASONALITY

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January June 2018 25 periods are counted as a continu ation of the prevailing trend. Vector Hazard score ( 0-1.0 ): (Rank) / (Maximum rank) (An nual Aedes chosen) In theory, this scale could range from 0 to 1.0 based on the high est rank of vector distribution and activity throughout the year at the not rely solely on this metric to Area (sq km): Area of the second order administrative region. Number of people: Estimated number of people within the sec ond order administrative region according to Landscan. Average density of people (sq km): Average density of the sec ond order administrative region derived from Landscan. Control advice: A text descrip tion of where in the seasonal cycle of Aedes and place represents. Warning: text advice is based on changes in rank, which can result in un expected results. For example, although probability may change over time in a minor ferent ranks, which can exaggerate the perception of change and lead to spurious advice. The user is advised to always consult the accompanying graph to gauge the veracity of the automated advice. Advice for each posi tion of the cycle can be tailored by editing contents of cells EJ17:EJ24. Possible advisory warnings that could be triggered for the 6 time periods shown in Figure 1 include: 1. Aedes munity education. 2. Aedes Maintain vector control and community education. 3. Aedes control and community education. Be aware that peak in cases can lag peak in vectors. 4. Aedes pare for scaling up vector control. 5. Aedes Initiate vector control and community education. 6. Aedes education. include consultation with vector control and public health personnel. Seasonality Graphics Presentations In addition, Figure 2 presents a graph which displays the seasonal pattern in Aedes suitability (blue line) and the A B Figure 1 Typical seasonal pattern of modelled Aedes probability over a year divided into 2 week periods for Esprito Santo-Alfredo Chaves, Brazil. Section A: Boxed numbers indicate important date points in this seasonal pattern, as described in the text. Section B: Outputs for various metrics for the 6 date points shown in section A.

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26 http://www.cs.amedd.army.mil/amedd_journal.aspx the location of the administrative region selected. Figure 3 shows the results of clustering Aedes seasonality into 2 a northern cluster and a geographically larger southern cluster. The northern cluster shows a peak in March to April and a trough in July to December, while the south ern cluster peaks in December to March and exhibits a pronounced trough in May to September. With 6 iso clusters, the northeastern region shows a more compli cluster are shown in Figure 3. The continuous PC map shows the most complicated pattern. torMap website, http://vectormap.si.edu/. CO MM ENT Knowledge of vector seasonality is powerful intelli gence about when vector to human contact is expected, and disease transmission risk. In this article, we dem onstrate the potential utility of global habitat suitabil ity models to predict Aedes ( Ae. aegypti ) seasonality Excel spreadsheet interface that calculates metrics and risk assessment for Ae. aegypti vectored diseases such as dengue, chikungunya, yellow fever, and Zika. We believe that this approach adds value to monthly habi tat suitability models by allowing a wide variety of us ers to explore seasonal patterns for any area of interest. is important as it informs time-sensitive vector control, prophylaxis, and travel decisions. Faria et al 10 was a strong association between estimated climatic no time lag was evident. The observation that Aedes seasonality iso clusters (Figure 3) are most diverse in example, if transmission occurred in iso clusters 3, 5 or 6 that experience earlier suitability for Aedes, cases may appear around the time of peak suitability for the other iso cluster areas. This tool could be extended for other areas of interest where a polygon or point feature delimiting the area is available. The authors are currently exploring extend ing this tool to other countries such as Colombia, Puerto Rico, and Thailand. If monthly models of habitat suit ability or abundance for Ae. aegypti or other vector spe cies become available, these can be used with the cur rent Excel interface. There are a number of limitations with our approach, a few of which are discussed herein: As the primary out areas of interest should not be too large, or cover topo logically diverse areas, as the range of values can show high diversity not adequately captured in the mean. Ide ally, areas should show a clear seasonal pattern, as areas that are not suitable for the vector or have uniformly low Figure 2 Output sheet for the Brazil Aedes /Zika Excel tool showing (left) inputs for location and date and outputs; (center) output line chart; and (right) map of Brazil with location. EXCEL TOOL FOR AEDES VECTOR SEASONALITY

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January June 2018 27 or high suitability will give spurious results for the met rics that rely on ranking used here. The use of ranks can introduce a false sense of seasonal change and should always be considered alongside the actual values; the graph of change in habitat suitability values in the tool suggestions regarding response to the position in the this tool under development and the user should show caution in following these suggestions. The seasonal predictions are only as good as the model underpinning this tool; the current model may not accurately show what happens in future years. The relationship of vector habitat suitability to disease risk is not always obvious and appears to vary depending on the region. In addi tion, consideration of lag and congenital Zika syndrome should take into consideration the full 9 months of preg date backward an appropriate amount to gauge how past Aedes nally, ZIKV can be imported and spread by nonvector transmission routes (eg, sexual transmission 13 ), so a level of caution is recommended when trying to relate monthly vector habitat suitability models and areas of interest for those lacking the time and skills to use learn and deploy GIS software. Ideally, this platform would be made available via a web-based interface. However, many users need to access this tool in austere environ ments where internet connectivity is unreliable or com pletely unavailable. The MS Excel-based platform can be downloaded before deployment and run on any lap top or desktop computer without the need for an internet connection. The Excel tool we developed is an acces sible and adaptable platform for entomological decisionmaking that makes use of readily available data and models. As a new model becomes available, it can be easily incorporated into this tool. Validation of the out put from this tool using mosquito surveillance results, and obtaining user feedback, would be useful goals for future research. ACKNOWLEDG M ENTS cess to the models of Aedes suitability. We also thank MAJ Wes McCardle (Chief, Walter Reed Biosystemat tool. This study was made possible from a FY2017 grant (P0091_17_WR_1.3.1.) from the Armed Forces Health Surveillance Branch and its Global Emerging Infections Surveillance Section. REFERENCES 1. Lindholm DA, Myers T, Widjaja S, et al. Mos quito exposure and Chikungunya and Dengue in fection among travelers during the Chikungunya outbreak in the Americas. Am J Trop Med Hyg 2017;96(4):903-912. Figure 3 Aedes aegypti seasonality for second order administrative regions of Brazil reduced to 2 iso clus ters, 6 iso clusters, and 3 (red, green, blue) principal components. Note the mean seasonality (probability per month) as graph for each iso cluster.

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28 http://www.cs.amedd.army.mil/amedd_journal.aspx 2. Grard G, Caron M, Mombo IM, et al. Zika vi rus in Gabon (Central Africa)-2007: a new threat from Aedes albopictus ?. PLoS Negl Trop Dis 2014;8(2):e2681. 3. Aedes aegypti mosquitoes in the Americas. J Infect Dis 2016;214(9):1349-1356. Available at: https://doi. org/10.1093/infdis/jiw302. Accessed June 18, 2018. 4. Ferreira-de-Brito A, Ribeiro IP, Miranda RM, Fer nandes RS, Campos SS, Silva KA, et al. First de tection of natural infection of Aedes aegypti with Mem Inst Oswaldo Cruz 2016;111(10):655-658. doi: 10.1590/0074-02760160332. 5. sheet for estimating Zika risk and timing for Zika an example. US Army Med Dep J January-June 2017:34-46. 6. tial for Zika virus introduction and transmission in resource-limited countries in Africa and the Lancet Infect Dis 2016;16(11):1237-1245. doi: 10.1016/ S1473-3099(16)30270-5. 7. temperature constraints on Aedes aegypti and Ae albopictus persistence and competence for dengue virus transmission. Parasit Vectors 2014;7:338. 8. Lambrechts L, Paaijmans KP, Fansiri T, et al. Im virus transmission by Aedes aegypti Proc Natl Acad Sci U S A 2011;108(18):7460-7465. 9. Shearer FM, Barker CM, et al. The global distri bution of the arbovirus vectors Aedes aegypti and Ae. albopictus ELife eLife.08347. 10. JG, Giovanetti M. et al. Establishment and cryp Americas. Nature. 2017; 546:406-410. doi:10.1038/ nature22401 11. Foy BD, Kobylinski KC, Chilson Foy JL, Blitvich BJ, Travassos da Rosa A, Haddow AD. et al Prob able non-vector-borne transmission of Zika virus, Emerg Infect Dis 2011;17:880-882. AUTHORS Dr Foley is a Research Entomologist at the Walter Reed Army Institute of Research, and a Research Associate of the Entomology Department within the National Mu seum of Natural History, located at the Smithsonian In stitution, Museum Support Center, Suitland, Maryland. Mr Pecor is a Research Technician at the Walter Reed Army Institute of Research, located at the Smithsonian Institution, Museum Support Center, Suitland, Maryland. EXCEL TOOL FOR AEDES VECTOR SEASONALITY Aedes albopictus (courtesy of the CDC) Aedes aegypti (courtesy of the CDC)

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January June 2018 29 Thailand serves as a center for a multinational Asia(CBG) that brings together military personnel from the est multinational military exercise hosted by Thailand activities include humanitarian missions such as con struction of schools or multipurpose buildings for the community as well as vironments. In each year since 1982, more than 13,000 have participated in the exercises that are held in many regions of Thailand. The training usually occurs be tween January and March, within the hot and dry season distribution of wild animals, rodents, arthropod vectors, and hence pathogen transmission. 1,2 The CBG training sites are usually in rural or semirural areas making them diseases posing risks to the training troops. To address Armed Forces Research Institute of Medical Sciences a vector-borne and rodent-borne disease surveillance program in 2017 in support of CBG training exercises. The aim of this surveillance was to evaluate potential risk of vector-borne and rodent-borne disease infections and hence establish a more accurate risk assessment for these diseases. Such information is particularly useful to regional and combatant commanders for timely and focused implementation of personal protective measures and disease prevention and control programs. Some of the major vector-borne diseases of public health importance in this region include scrub typhus, rick ettsioses, 3,4 and leptospirosis; all associated with small mammals and their ectoparasites, especially rodents in rural and semirural settings. Most common clinical signs and symptoms of rickettsial diseases and leptospi rosis are reminiscent of other infectious diseases such as malaria, typhoid fever, and dengue fever, which are ferential diagnosis from various other febrile illnesses ated with these diseases still remain largely unknown. Among arthropod-borne diseases, scrub typhus was a major cause of morbidity and mortality in military op 5 It Surveillance for Scrub Typhus, Rickettsial Diseases, and Leptospirosis in US and Multinational Military Training Exercise Cobra Gold Sites in Thailand Piyada Linsuwanon, PhD Surachai Leepitakrat, MS ABSTRACT :H\003UHSRUW\003\277QGLQJV\003RI\003\277HOG\003VXUYHLOODQFH\003IRU\003GLVHDVH\003YHFWRUV\003DQG\003WKH\003SUHYDOHQFH\003RI\003 Orientia tsutsugamushi, the causative agent for scrub typhus, and other Rickettsial species that cause murine typhus and spotted fever group rickettsioses, in chigger mites and small rodents; and Leptospira in rodent kidney, urine, and environ mental water samples. The study sites included various Royal Thai Army military installations and other train ing sites, and surrounding areas where the multinational military training exercise Cobra Gold was conducted in Thailand in 2017 and 2018. The overall prevalence of O. tsutsugamushi and Rickettsia infection in chiggers was 1.3% (20/1,594) and 7.5% (119/1,594), respectively. Serum samples of the captured rodents indicated previ ous exposure to O. tsutsugamushi infection with a seropositive rate of 12.2%. Leptospira species were isolated from rodent kidneys and water samples collected from catchment areas as well as tap water used for hand wash ing. Findings from this surveillance are important in determining the potential for scrub typhus, rickettsioses, ant commanders for prevention, correct diagnosis, prompt treatment, and timely and focused implementation of vector control and personal protective measures.

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30 http://www.cs.amedd.army.mil/amedd_journal.aspx is caused by the infection of Orientia bacteria which is transmitted to humans through the bite of infected trom biculid larval mites, commonly referred to as chiggers, which serve as vectors and main reservoirs of this patho genic bacterium. 1 The chiggers primarily feed on rodents but occasionally on humans, presenting an opportunity to transmit the Orientia bacteria. Scrub typhus is pre commonly referred to as the Tsutsugamushi Triangle that extends from northeastern Japan to Pakistan and Afghanistan in the west and northern Australia in the south, although there have been recent reports of scrub typhus outside this region. Approximately one million cases occur in the endemic areas each year and more than a billion people are at risk worldwide. 6 Typically, patients with scrub typhus respond well to doxycycline, evidence of potential doxycycline-refractory Orientia tsutsugamushi (Tamura) strain have been reported in northern Thailand, 7 antibiotic treatment and the growing level of drug-resis prevent this disease. The current prevention method is mainly vector control and avoidance of exposure. Murine typhus is one of the typhus group rickettsiosis. subtropical areas of the world. 8 Xenopsylla cheopis (Rothschild), has been considered the main vec tor. Murine typhus is caused by infection with Rickett sia typhi enter the body through the bite site during feeding of contaminated feces into the bite site during scratching by the host. Spotted fever group rickettsiosis is a tickof bacteria in the genus Rickettsia such as R. honei (Hone), R. felis (Bouyeret), R. japonica R. helvetica (Beati). The disease is endemic throughout the world although the prevalence varies from region to re gion. Information on spotted fever rickettsiosis has only rarely been documented in Thailand, 9-11 although many regions have suitable environment for arthropod vectors and pathogens. The actual burden of murine typhus and spotted fever rickettsiosis in Thailand is still underesti mated and not well understood. Leptospira species are the causative agents of leptospirosis, being spread many wild and domestic reservoir hosts. 12,13 Its trans mission occurs when animals are exposed to Leptospira fected reservoir hosts via urine into the environment. 14 Generally, humans are accidental hosts and acquire the disease by indirect contact with water or soil contami nated with urine of infected animals or by direct expo sure to infected animal tissue or urine. 13,14 Infections vary in severity from mild, self-limiting febrile illnesses to more serious life-threatening conditions. Numerous came infected during an obstacle course at the Jungle Warfare Training Center, Camp Gonsalves in northern 15 In Thailand, leptospirosis is a reportable disease to the Bureau of Epidemiology, Department of Disease Con trol, and Ministry of Public Health. Most infections are reported from agricultural workers, primarily rice farmers, due to their tendency to work bare-footed in the 16 The incidence of leptospirosis is underestimated because only clinically diagnosed cases are reported and symptoms often resembles other febrile illnesses leading to misdiagnosis. 13 An overview of the national surveillance system for leptospirosis in Thailand indi is an inability to link clinical, epidemiologic, and labora tory data. 17 A lack of knowledge in naturally circulating Leptospira tionship is critical to deciphering disease epidemiology and is also useful for risk communication. Small rodents are widespread and are considered as im play an important role in the survival and ecology of lice. Conducting activities in close proximity to rodents habitats may lead to an increased risk of disease trans mission. In this study, we investigated the occurrence of disease vectors and prevalence of scrub typhus, rickett sioses, and leptospirosis in small rodents, chiggers and water samples collected from the CBG exercise areas of Thailand during the 2017 and 2018 training periods. MATERIALS AND METHODS Study Sites The study sites included select sites where CBG training exercise took place. In 2017, surveillance was conduct Rum, Khon Kaen, Chanthaburi, and Rayong. In 2018, the selected CBG surveillance sites were in Nakhon SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND

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January June 2018 31 Ratchasima, Chachoengsao, Lopburi, Chanthaburi, and Rayong. Small rodents and ectoparasites were collected from the actual training sites and surrounding areas to cover as many habitats as possible. Also, water samples were collected from water bodies in the vicinity of the training sites as well as from taps used for cleaning and hand washing at students dining halls and toilet facili ties. Summaries of study site, survey period, number of rodents captured and rodent infestation rate per site is presented in Table 1 and Figure 1. Collection of Small Rodents and Water Samples All procedures involving animals were conducted in compliance with the animal use protocol (PN15-06: Field sampling of small mammal populations to support live traps measuring 14 cmx14 cmx28 cm were used. Rodents were baited with bananas, potatoes, palm seeds, or other types of food that are commonly found in the trapping areas or were recommended by local hunters. A total of 60 to 80 traps were set per night in each site before sunset (around 4 and collected the following morning before 8 Locations of the surveillance sites were recorded using handheld GPS trackers (Garmin Rodent Processing and Sample Collection ide. Blood samples were collected by postmortem car diocentesis and aliquoted into serum separator tubes. To the rodents due to the decrease in body temperature, the tic bags and fumigated using ether for 5 minutes. Ecto collected using paint brushes. Carcasses were inspected and the fur of each rodent was thoroughly examined us into plastic trays. Ectoparasites were stored in collec tion tubes containing 70% ethanol. Clusters of chiggers on rodent ears, bodies, or genital areas were collected together with the thin layers of skin to prevent damage and preserved in 70% ethanol. ic key of small mammals of southeast Asia. For tissue sample collection, the surface of the rodent abdomen was cleaned with 70% ethanol before necropsy. Rodents were dissected and internal organs including lung, liver, kid ney, and spleen were harvested. Serum and tissue sam ples were stored in dry-ice containers and transported to samples were later stored at 80C until further analysis. Table 1 Diversity of small rodents captured from study sites, load of chigger infestations, seropositivity, and Orientia and Rickettsia sp. positivity rates by rodent species. Order Family Species (No. rodents caught) Seropositivity (No. seropositive rodents) Pathogen Detection in Rodent Hosts Chigger STG MT SFG STG RT Infestation Total Chigger Rodentia Muridae Bandicota indica ( 57 ) 11 1 ( 5 ) 5 3 ( 3 ) a 64 9 ( 37 ) b 2,441 ( 1 328 ) c Bandicota savilei ( 51 ) 8 9 (4) 76 5 ( 39 ) 3,831 (2 338) Berylmys berdmorei ( 3 ) 4 4 (25) 100 ( 3 ) 18 (4 9) Mus caroli ( 4 ) NA NA NA Mus cervicolor ( 6 ) NA NA NA 16 7 ( 1 ) 30 (30) Niviventer fulvescens ( 1 ) NA NA NA 100 ( 1 ) 43 (43) Rattus berdmorei ( 25 ) 2 2 (1) Rattus exulans ( 78 ) 15 6 ( 7 ) 25 (1) 1 3 ( 1 ) 5 1 (4) Rattus norvegicus ( 4 ) 4 4 (25) Rattus tanezumi ( 189 ) 53 3 ( 24 ) 75 ( 3 ) 100 ( 25 ) 1 1 ( 25 ) 1 1 ( 25 ) 65 6 ( 124 ) 12,592 (4-595) Sciuridae Menetes berdmorei ( 16 ) NA NA NA 12 5 ( 25 ) 341 ( 5 236 ) Insectivora Tupaiiae Tupaia belangeri ( 3 ) NA NA NA Tupaia glis ( 25 ) NA NA NA 2 Orders 3 Families 13 Species 12 2 ( 29 ) 1 3 ( 3 ) 0 8 ( 25 ) 1 2 ( 3 ) 2 3 (6) 64 1 ( 207 ) 19,296 STG indicates scrub typhus group; MT, murine typhus; SFG, spotted fever group; RT, Rickettsia species. Notes concerning numbers in parentheses: a. Number of rodents with active infection of the target pathogen. b. Number of rodent host with trombiculid chigger. c. Range of chiggers collected per hour.

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32 http://www.cs.amedd.army.mil/amedd_journal.aspx SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND Figure 1 Distribution map showing (A) locations of the cobra gold training exercise during the training period of 2017 and 2018 together with average of inci dence of scrub typhus cases between 2016 and 2018 ; (B) Orientia (OT) and Rickettsia (RT) positivity in trombiculid chiggers; (C) Seropositivity of antibodies to scrub typhus (STG), murine typhus (MT) and spotted fever rickettsiosis (STG) among rodent population trapped in the training sites.

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January June 2018 33 Morphological Identification of Chigger Mites Approximately 10% of chiggers from each rodent were keys previously described by Nadchatram et al 18 and other published taxonomic keys. Slide-mounted chig gers were examined under a dissecting microscope at maining chiggers were transferred to 95% ethanol for better preservation of nucleic acid and further pathogen testing. Detection of Antibodies Reaction against O. tsutsugamushi and Rickettsia spp. in Rodents antibodies to the causative agents of scrub typhus, mu rine typhus, and spotted fever group rickettsioses us 19 Types of whole cell antigens used for IFA included a mixture of O. tsutsugamushi genotype Karp, Kato, and Gilliam for scrub typhus group antibody assessment, R. typhi isolate Wilmington for murine typhus assessment, and R. honei isolate TT112 for spotted fever group rick ettsiosis. Rodent sera were initially screened at the dilu and tested for antibody titer. Leptospira Cultures Isolation of Leptospira rouracil-containing Ellinghausen-McCullough-John son-Harris (EMJH) medium (Becton, Dickinson and Company, Franklin Lakes, New Jersey) with 5% rabbit maintained by the use of a Bunsen burner containing ile syringes and needles and dropped in 3 mL of 0.1% semisolid EMJH medium. A section of the cortex from suspended in 5 mL culture EMJH media and debris tissue allowed to precipitate. After 24 hours, 500 L of the culture was pipetted and subcultured into 3 mL semisolid EMJH medium and stored at room tempera water samples, EMJH medium was inoculated with were subpassaged as described earlier. The culture vials were incubated at 30 C for 16 weeks with biweekly dark Leptospira Pathogen Detections by PCR Detection of O. tsutsugamushi and Rickettsial Species in Rodents and Chiggers Nucleic acid was individually extracted from 3 or 4 types of rodent tissues including liver, lung, spleen, and/ or kidneys and chigger samples using MagAttract 96 ca dor pathogen kit (Qiagen Bioinformatics, Hilden, Ger many) following manufacturer protocol. The presence of O. tsutsugamushi and Rickettsia DNA were evaluated using quantitative real-time PCR (qPCR) assay targeting 47-kDa high temperature transmembrane protein ( HtrA ) ous described protocols as shown in Table 2. The qPCR analysis was performed in triplicated reactions and car (Bio-Rad Laboratories, Inc, Hercules, California). Detection of Leptospira DNA in Trapped Rodents and Water Samples The kidney specimens were subjected to genomic DNA extraction using the QIAmp DNA Mini kit (Qiagen) ac ent qPCR assays were used for Leptospira DNA detec tion. The lipL32 qPCR was used to detect the Leptospira DNA in the rodents kidney specimens, 22 while the qPCR assay targeting 16s rRNA gene ( rrs ) gene was used to detect the Leptospira DNA in the water samples (Table 2). 23 For collected water evaluation, 50 mL of water was centrifuged at 3,000 g for 30 minutes to concentrate the bacterial cells. The pellet was resuspended in 140 the suspension using the QIAamp Viral RNA Mini Kit (Qiagen) following the manufacturers protocol. Positive controls included DNA samples prepared from reference L. interrogans culture, Leptospira -infected rodent kid ney tissues, and Leptospira positive water samples col lected during previous sur veillance studies. The DNA prepared from nonpatho genic culture and from noninfected rodents tissue was used as negative controls. Table 2 Summary of pathogen detections by PCR. Pathogen Target Gene Detection Method Type of Samples Reference Protocol Orientia tsutsugamushi 47 -kDa HtrA qPCR Rodent tissue, chigger Jiang et al 20 Rickettsial sp. 17 -kDa qPCR Rodent tissue, chigger Wright et al 21 Leptospira spp. lipL 32 qPCR Rodent tissue McAvin et al 22 16 s rRNA qPCR Water sample Smythe et al 23 16 s rRNA nPCR Leptospira culture medium Boonsilp et al 24 16 s rRNA nPCR Leptospira qPCR positive sample Boonsilp et al 24

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34 http://www.cs.amedd.army.mil/amedd_journal.aspx The nested single tube PCR assay targeting partial rRNA gene was performed on positive lipL32 and rrs qPCR assay samples as previous described. 24 Amplicons were determined using 1.5% gel electrophoresis followed by PCR products were sent to Macrogen, Inc (Seoul, South Korea) for sequencing. The DNA sequences of partial rrs ware (Gene Codes Corporation, Ann Arbor, Michigan) and trimmed to the 433 base pair length fragments. For Leptospira species, the DNA fragments were compared to available Leptospira se quences in the GenBank database using the Basic Local Alignment Search Tool (BLASTn) algorithm. Identification of Recovered Leptospira Isolates Using 16 S Rrna Gene Amplification The isolated Leptospira was regrown in liquid EMJH at 30C for 7 days and total genomic DNA extracted from tion kit (Thermo Fisher) according to manufacturers in structions. The nested single tube PCR assay and analy sis were performed as described earlier. Data Management and Statistical Analysis Digital map for seropositive rodents and ectoparasites infected with Orientia and Rickettsia pathogens were created using qGis v 2.18.16 (https://qgis.org/en/site/). The epidemiological parameters and indices were calcu lated according to the guidelines recommended by the 25,26 The parameters included rodent infestation rate (number of captured rodents from number of traps), mean abundance (number of chiggers collected per number of examined rodents), chigger in festation rate (percentage of rodents infested with chig individual hosts), and overall chigger index (total num ber of chiggers collected [regardless of species] per total SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND Table 3 Overall percentage infestations of rodents and trombiculid chiggers, and seropositivity and pathogen positivity by col lection sites. CBG Collection Site (No. rodents caught) Collection Periods Rodent Chigger Seropositivity (No. of assayed) Pathogen Positivity Infestation Rate Chigger Infestation No. Chiggers Chigger Index STG MT SFG STG RT 2017 Buri Ram ( 125 ) 2017 : April, October 23 6 (125/530) 33 6 (42/125) 7,974 189 9 8 1 (10/123) 2 4 (3/125) 4 (5/125) Chaiyaphum ( 48 ) 2017 : January, March, July 11 4 (48/420) 75 (36/48) 1,763 49 3 13 6 (6/44) Chanthaburi ( 23 ) 2017 : January, September 1 3 (6/480) 21 7 (5/23) 20 4 0 15 (3/20) 4 3 (1/23) Khon Kaen ( 62 ) 2017 : January, March, July 13 8 (62/450) 21 (13/62) 1,132 87 1 20 (10/50) 6 (3/50) 4 (2/50) Rayong ( 3 ) January 2017 1 (2/200) Total: 261 36 8 (96/261) 10,889 113 5 12 2 (29/237) 1 3 (3/237) 0 8 (2/237) 1 2 (3/261) 2 3 (6/261) 2018 Chachoeng Sao ( 9 ) December 2017 44 4 (4/9) 111 27 8 Chanthaburi ( 51 ) January 2018 22 4 (51/228) 72 5 (37/51) 3,110 84 1 25 5 (13/51) Lopburi ( 54 ) December 2017 15 4 (54/350) 77 8 (42/54) 3,804 91 9 1 8 (1/54) 3 7 (2/54) Nakhon Ratchasima ( 18 ) November 2017 44 4 (8/18) 97 12 1 Rayong ( 23 ) January 2018 17 3 (23/133) 87 (20/23) 1,285 64 3 13 (3/23) 4 3 (1/23) Total: 155 71 6 (111/155) 8,407 76 3 10 8 (16/148) 0 7 (1/148) 1 9 (3/155) Grand Total: 416 49 8 (207/416) 19,296 93 2 0 72 (3/416) 2 2 (9/416) 0 72 (3/416) 0 72 (3/416) 2 2 (9/416) CBG indicates Cobra Gold; STG, scrub typhus group; MT, murine typhus; SFG, spotted fever group; RT, Rickettsia species. Notes concerning numbers in parentheses: number of captured rodents/number of traps deployed number of rodents infested with chiggers/total number of captured rodents

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January June 2018 35 number of infested hosts). The index was multiplied by 100 to give the percentage index. Correlation analysis was performed to determine association between sero positivity, prevalence of chigger infestation on the ro dent, chigger index, and qPCR positivity rate of target pathogen in chiggers. RESULTS Abundance of Rodents and Chigger Mites Were Found in CBG Training Exercise Sites In total, 416 small rodents including rats, mice, and tree-shrews representing 7 genera and 13 species were collected (Table 1). A total of 261 rodents (62.7%) were collected in 2017 (CBG 2017) and 155 rodents (32.3%) trapped in 2018 (CBG 2018) (Table 3). Rodent and ec toparasite populations were surveyed for 37 trap nights at 39 sites covering most of the CBG training exercises sites and surrounding areas (Figure 1). Rodents were successfully trapped from all of the training sites with variations in infestation rates among sites. The CBG 2017 training site located at Buriram and areas adjacent to the training sites were heavily infested with rats with the overall infestation rate of 23.6%. For CBG 2018, the rate of rodent infestation was highest in Chanthaburi (22.4%) and Rayong (17.3%). The Asian house rat, Rat tus tanezumi (Kloss) considered the main reservoir host rodents, 207 were infested with chiggers which cor responded to 49.7% prevalence of chigger infestation. should be considered as areas at high or moderate risk for rodent-borne and ectoparasite-borne diseases. Diversity of Chigger Population Chiggers were found in all study sites, except the CBG 2017 Rayong site. Seven of 13 rodent species were in fested with chiggers. The main reservoir hosts of trom biculid chiggers included Berylmys berdmorei (Blyth) Bandicota savilei (Thomas) R. tanezumi (Temminck ), and B. indica (Bechstein). The overall chigger index in dicated that chiggers were most abundant in the CBG 2017 Buriram site (189.9), followed by CBG 2018 Lop buri site (91.9), and CBG 2017 Khon Kaen site (87.1). A total of 19,296 chiggers belonging to 7 genera were chigger infested rodents, 158 (76.3%) rodents were infested with trombiculid chiggers from a single genus, while 43 (20.8%) and 6 (2.9%) rodents harbored chiggers from 2 and 3 gen rodents hosted 1.270.5 gen era (meanSEM) of chiggers. The most abundant chiggers belonged to the Walchai spe cies (26.9%) followed by chig gers from Ascoschoengastia sp (33.3%), Leptotrombidium sp (21.7%), and Scheogastia sp (13.5%). Chiggers from Helenicula sp (1.4%), Blankaar tia sp (1%) and Trombiculindus sp (0.5%) were found in only few rodents (Table 4). Prevalence of O. tsutsugamushi and Rickettsia DNA in Trombiculid Chiggers A total of 1,594 nucleic acid samples extracted from 3,489 chiggers were tested. The sample set consisted of 1,297 samples extracted from individual chiggers and 297 samples extracted from pools of 2,192 chig gers (5 to 10 chiggers per pool). Orientia positivity rate in chiggers was 1.3% (20/1,594) (Table 5). The mean of Orientia pathogenic bacteria load detected in individual chiggers ranged from 13.8 to 2,251.6 cop ies/l. The positive chiggers were recovered from 18 Table 5 Numbers of trombiculid chiggers positive for Orientia and Rickettsia by genus. Genera Number of Positive Samples Study Site RT STG Ascoshoengastia 4 Chaiyaphum, Khon Kaen Gahrliepia 70 6 Chaiyaphum, Buriram, Chanthaburi Lopburi, Rayong, Chachoeng Sao Helenicula 1 2 Khon Kaen Leptotrombidium 39 5 Chaiyaphum, Chanthaburi, Khon Kaen, Rayong Scheongastia 9 3 Buriram Total 119 20 RT indicates Rickettsia species; STG, scrub typhus group. Cobra Gold 2017 Cobra Gold 2018 Table 4 Chigger genus composition among small rodent species. Rodent Species (No. of rodents caught) Genus of Chigger Lepto Scheo Ascos Walch Blank Helen Trombi Bandicota indica (57) 194 (7) 70 (1) 12 (3) 2,162 (36) 3 (1) Bandicota savilei (51) 154 (4) 3,677 (39) Berylmys berdmorei (3) 18 (3) Menetes berdmorei (16) 336 (1) 5 (1) Mus cervicolor (6) 30 (1) Niviventer fulvescens (1) 43 (1) Rattus tanezumi (189) 1,006 (32) 4,706 (26) 5,164 (66) 1,614 (41) 2 (1) 98 (3) 2(1) Total: 323 1,733 (45) 4,781 (28) 5,176 (69) 7,501 (120) 5 (25) 98 (3) 2(1) Lepto indicates Leptotrombidium ; Scheo, Scheogastia ; Ascos, Ascoschoengastia; Walch, Walchia ; Balnk, Blankaartia ; Helen, Helenicula ; trombi, trombiculindus

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36 http://www.cs.amedd.army.mil/amedd_journal.aspx individual rodents. 66.6% (12/18) rodents were caught in the training exercise sites, indicating that there may be a high risk of scrub typhus disease transmission. The rodent species with positive chiggers were R. tanezumi (72.2%, 13/18); B. savilei (22.2%, 4/18); and B. indica (5.6%, 1/18), respectively. Rattus tanezumi was the only species complex that showed correla tion between seropositivity to O. tsutsugamushi load of chigger, and its prevalence infection in Rickettsia DNA in trombiculid chigger samples in Thai land. Rickettsial pathogens were detected in 119 (7.5%) samples with an average bacterial load Ascoshoengustia sp. chiggers had Orientia and Rickettsia bacteria coinfection. Seroprevalence of O. tsutsugamushi and Rickettsia Infection in Wild Rodents Secondary antibodies for some of rodent spe cies such as Tupia species are not commercially available, hence 7.4% of the rodents were ex dents examined, 45 rodents (11.7%) captured from 6 of 10 CBG training exercise sites were seropositive for antibodies to O. tsutsugamu shi -antigen group (Table 1). The highest sero prevalance to O. tsutsugamushi was the CBG 2018 Chanthaburi site with (25.5%), followed by the CBG 2017 Khon Kean (20%), Chanthaburi (15%), and Chaiyaphum (13.6%) sites, the CBG 2018 Rayong site, and the CBG 2017 Buriram site (8.1%). Seropositive rodents against O. tsu tsugamushi antigens were detected in 7 rodent species: R. berdmorei (50%, 1/2), R. norvegicus (50%, 1/2), B. berdmorei (66.7%, 2/3), R. tan ezumi (12.7%, 24/189), R. exulas (9%, 7/78), B. indica (8.8%, 5/57), and B. savilei (7.8%, 4/51). rodent species, but not among the study sites. Correlation between chigger and seropositiv ity was only found in 3 rodent species; R. tan ezumi B. indica and B. savilei ( P <.0001, 95% seropositive to rickettsial pathogens with 1% of R. typhi 4 and 0.5% of R. honei 27 Almost all of the seropositive rodents were caught from the training site in Khon Kaen, except one rodent that was seropositive to R. typhi which was col lected from the Lopburi training site. Mixed found in rodents captured from the Khon Kaen SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND Figure 2 Genus composition of chigger population recovered from spe Total no. trombiculid chiggers Gahrilepia ( Walchia ) Trombiculindus Helenicula Blankaartia Ascoschoengastia Leptotrombidium 1 0.1 1000 10 100 Bandicota savilei Rattus tanezumi Total no. trombiculid chiggers 1 0.1 1000 10 100 Gahrilepia ( Walchia ) Trombiculindus Helenicula Blankaartia Ascoschoengastia Leptotrombidium Total no. trombiculid chiggers Bandicota indica Gahrilepia ( Walchia ) Trombiculindus Helenicula Blankaartia Ascoschoengastia Leptotrombidium 1 0.1 1000 10 100

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January June 2018 37 bodies to O. tsutsugamushi and R. honei while another rodent had antibodies to R. typhi and R. honei The presence of Orientia and Rickett sia DNA in rodents was examined. The of 47-kDa HtrA gene and 17-kDa gene was 97% and 101.3%, respectively. R 2 of the standard curve was 99.4 for both of 47-kDa HtrA and the 17-kDa genes. Orientia species DNA was detected only in lung samples of 3 rodents (0.7%, R. tane zumi (1.1%, 2/189) and R. exulans (1.3%, 1/78) were positive. All of the Orientia positive rodents were caught from the training areas in Buriram province. A total of 9 rodents had active rickettsial pathogens infections (2.2%, 9/416). All Rickettsia positive rodents were collected from traps from villages and plantations near the training sites of Buriram, Chanthaburi, Lopburi, and Rayong (Table 3). Rickettsia DNA was found in many organs with the highest prevalence in lung (66.7%, 6/9), followed by kid ney (22.2%,2/9) and liver (11.1%, 1/9), respectively from 3 rodent species, including R. exulans 4 B. indica 3 and R. tanezumi 27 Detection of Leptospira spp. in Rodent Tissue and Water Samples During the 2017 surveillance, all of the rodents were shown to be Leptospira negative by the qPCR assay targeting the lipL32 collected from puddles, rivers, canals, and tap water around the training sites and tested for Leptospira by qPCR assay targeting rrs gene, none of the samples was positive for Leptospira. However, 3 samples were posi tives in the EMJH media culture (Table 6). Two of these samples were recovered from the pond in the school and water source in the village around training site in Chaiyaphum. The other isolate was recovered from the rrs Results obtained from BLASTn search and phylogenetic analysis of rrs intermediate L. licerasiae During the 2018 surveillance period a total of 155 rodents and 105 water samples were determined for Leptospira DNA. Two rodents (1.3%), Mus cervicolor (Hodgson) from Nakhon Ratchasima and R. tanezumi from Chanthaburi, were positive for Leptospira infec tion. Thirty-three of 105 (31%) water samples from 5 areas were positive for Leptospira by rrs real-time PCR detection. Three of the positive water samples were col lected from Nakhon Ratchasima, 2 from Chachoengs ao, 5 from Lopburi, 6 from Chanthaburi, and 17 from Rayong. Eight isolates of Leptospira were successfully recovered from culture. Two isolates from the site in Na khon Ratchasima were recovered from tap water near the construction site and another one from a canteen in the school. The positive culture sample from Chacho engsao and Lopburi were collected from the ponds near the school. Two isolates from Chanthaburi were recov ered from 2 tap water samples from a canteen. The last 2 isolates were the tap water samples collected from the CBG construction site in Rayong. CO MM ENT In this study, rodent trapping and collection of ectopara sites were used instead of the conventional black plate technique to cover larger areas where exposure to vec tor and pathogen might occur. In addition, due to the military operations, the movement of service members black plate method to be used to conduct surveillance in all potential risk areas. By using the rodent collection method, we successfully collected high numbers of trom with 49.8% of collected rodents having ectoparasites. Trombiculid chiggers were recovered from almost all training sites, except the CBG 2017 Rayong site because only few rodents were caught (n=3). A relatively high cated that certain rodent species appeared to host more chigger species than others. However, the correlation the prevalence of chigger load in rodent hosts was not Table 6 Summary of Leptospira positive samples. CBG Province Rodents Environmental Water Samples No. Trapped Rodents lipL32 qPCR Positive No. Samples rrs qPCR Positive Positive Culture 2017 Chaiyaphum 13 0 9 0 2 Chantaburi 6 0 10 0 0 Khon Khan 14 0 7 0 1 Rayong 3 0 10 0 0 Total 36 0 36 0 3 2018 Nakhon Ratchasima 18 1 22 3 2 Chachoengsao 9 0 22 2 1 Lopburi 54 0 21 5 1 Chantaburi 51 1 20 6 2 Rayong 23 0 20 17 2 Total 155 2 105 33 8 CBG indicates Cobra Gold.

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38 http://www.cs.amedd.army.mil/amedd_journal.aspx 25 or ies have demonstrated abundant trombiculid chiggers in various locations in Thailand, although information of from the available data previously reported from Thai land. By recalculating the data reported by Coleman et al, 28 we found that the chigger index was 59.5 (153,899 chiggers/2,587 infested hosts). Even though Coleman and colleagues conducted extensive rodent and chig ger surveillance studies in many regions in Thailand, most of the rodents (88%) were caught from Chiangrai province. Therefore, the overall chigger index seemed studies conducted in neighboring province of Chiang mai also showed a relatively similar high chigger index (50.6, 2,277/45). 29 In our study, a higher chigger index ing sites, the CBG 2017 Buriram site showed the high than the other sites. This suggested that Buriram site may be considered an area with a high risk of chiggerborne disease transmission to service members. Many species of trombiculid mites are important vec tors of Orientia collected, 5 genera: Walchai Leptotrombidium Ascos choengastia Helenicula and Scheogastia were positive for Orientia Rickettsia sp. infection in a large number of trombiculid chiggers in Thailand was reported for the Orientia and Rickettsia infected chiggers were recovered from rodents caught approximately 1 to 2 months before the CBG training exercise started. Based on our serosurveillance study, seropositivity of small rodents to O. tsutsugamushi infection was high in many training sites, with the highest seropositive rate in the CBG 2018 Chanthaburi site. Data for scrub typhus gether with data of scrub typhus patient obtained from the Thai Ministry of Public Health. Scrub typhus infec tion rate in Thailand over a 4-year surveillance period between 2014 and 2017 was high with a total of 31,199 cases reported. The number of scrub typhus cases var ied within seasons and regions. The vast majority of the of Thailand, followed by northeastern, southern, and central parts. According to the most recent annual re ports in 2016 and 2017, scrub typhus cases were found in all provinces where CBG took place. Leptospira pathogens in ro dent tissue and water samples may be an indication that activities associated with water, both ground and piped water, may be of concern especially to individuals with wounds or any break in the skin. Human infections oc cur when they come into contact with the contaminated environment and when the organism penetrates through broken skin or mucosa. A recent report from Dierk et al 15 investigated the association between training activi ties and the largest record of leptospirosis cases within relationship of water exposure in areas with high lepto spirosis levels increased the risk of symptomatic disease are well-known reservoirs of Leptospira and are often implicated as the source of human leptospirosis in Thai land. Environmental contamination by Leptospira is a of Leptospira in the environment. Therefore, the preva lence of infected rodents may serve as an indicator of Leptospira transmission throughout the environment. Findings from our surveillance indicate that scrub ty phus, rickettsial diseases, and leptospirosis that are widely distributed throughout Thailand pose a more the potential risk for scrub typhus, other rickettsial dis personnel, and for informing regional and combatant commanders for timely diagnosis, treatment and pre vention including focused implementation of personal protective measures and vector control in training ar eas. Continuous surveillance on the ecology, entomol ogy, and epidemiology of these public health important vector-borne diseases is warranted to provide a more accurate risk assessment and determine hot spots for these diseases to assist site selection and planning for future CBG training exercises. ACKNOWLEDG M ENTS The authors thank Sirima Wongwairot, Nutthanun Auysawasdi, Chawin Limsuwan, Taweesak Monkanna, assay. This research was supported by the Global Emerg ing Infections Surveillance and Response System, a di vision of the Armed Forces Health Surveillance Branch SURVEILLANCE FOR SCRUB TYPHUS, RICKETTSIAL DISEASES, AND LEPTOSPIROSIS IN US AND MULTINATIONAL MILITARY TRAINING EXERCISE COBRA GOLD SITES IN THAILAND

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January June 2018 39 REFERENCES 1. Lerdthusnee K, Nigro J, Monkanna T, et al. Surveys of rodent-borne disease in Thailand with a focus on scrub typhus assessment. Integr Zool 2008;3(4):267-273. 2. Wongkoon S, Jaroensutasinee M, Jaroensutasinee K. Distribution, seasonal variation & dengue transmis sion prediction in Sisaket, Thailand. Indian J Med Res 2013;138(3):347-353. 3. Jones KE, Patel NG, Levy MA, et al. Global trends in emerging infectious diseases. Nature 2008;451(7181):990-993. 4. A review of the global epidemiology of scrub typhus. PLoS Negl Trop Dis 2017;11(11):e0006062. 5. Kelly DJ, Richards AL, Temenak J, Strickman D, Dasch GA. The past and present threat of rickettsial diseases to military medicine and international public health. Clin Infect Dis 2002;34(suppl 4):S145-S169. 6. Watt G, Parola P. Scrub typhus and tropical rickettsio ses. Curr Opin Infect Dis 2003;16(5):429-436. 7. Watt G, Chouriyagune C, Ruangweerayud R, et al. Scrub typhus infections poorly responsive to antibiot ics in northern Thailand. Lancet 1996;348(9020):86-89. 8. Bitam I, Dittmar K, Parola P, Whiting MF, Raoult Int J Infect Dis 2010;14(8):e667-e676. 9. Strickman D, Tanskul P, Eamsila C, Kelly DJ. Preva lence of antibodies to rickettsiae in the human popu lation of suburban Bangkok. Am J Trop Med Hyg 1994;51(2):149-153. 10. Jiang J, Sangkasuwan V, Lerdthusnee K, et al. Human infection with Rickettsia honei Thailand. Emerg Infect Dis 2005;11(9):1473-1475. 11. Takada N, Fujita H, Yano Y, Huang WH, Khamboon ruang C. Serosurveys of spotted fever and murine ty phus in local residents of Taiwan and Thailand com pared with Japan. Southeast Asian J Trop Med Public Health 1993;24(2):354-356. 12. Bharti AR, Nally JE, Ricaldi JN, et al. Leptospirosis: Lancet Infect Dis 2003;3(12):757-771. 13. Faine S Adler B, Bolin C, Perolat P, eds. Leptospira and Leptospirosis Armadale, Australia: MediSci. 1999. 14. Ko AI, Goarant C, Picardeau M. Leptospira : the dawn pathogen. Nat Revs Microbiol 2009;7(10):736-747. 15. Dierks J, Servies T, Do T. A study on the leptospirosis pan. Mil Med 2018;183(3-4):e208-e212. 16. Tangkanakul W, Smits HL, Jatanasen S, Ashford DA. Leptospirosis: an emerging health problem in Thailand. Southeast Asian J Trop Med Public Health 2005;36(2):281-288. 17. Sejvar J, Tangkanakul W, Ratanasang P, et al. An out break of leptospirosis, Thailand--the importance of the laboratory. Southeast Asian J Trop Med Public Health 2005;36(2):289-295. 18. Nadchatram M, Dohany AL. A Pictorial Key to the Subfamilies, Genera and Subgenera of Southeast Asian Chiggers (Acari, Prostigmata, Trombiculidae) Kuala Lumpur, Malaysia: Institute for Medical Research; 1974. 19. Rodkvamtook W, Ruang-Areerate T, Gaywee J, et al. Orientia tsutsuga mushi from rodents captured following a scrub typhus outbreak at a military training base, Bothong district, Chonburi province, central Thailand. Am J Trop Med Hyg 2011;84(4):599-607. 20. Jiang J, Chan TC, Temenak JJ, Dasch GA, Ching WM, Richards AL. Development of a quantitative real-time Orientia tsutsugamushi Am J Trop Med Hyg 2004;70(4):351-356. 21. Wright CL, Nadolny RM, Jiang J, et al. Rickettsia parkeri Emerg Infect Dis 2011;17(5):896-898. 22. McAvin JC, Kengluecha A, Takhampunya R, Richard tospirosis causative agents in rodents. US Army Med Dep J July-September 2012:22-28. 23. Smythe LD, Smith IL, Smith GA, et al. A quantitative PCR (TaqMan) assay for pathogenic Leptospira spp. BMC Infect Dis 2002 Jul 08;2:13. 24. Boonsilp S, Thaipadungpanit J, Amornchai P, et al. Molecular detection and speciation of pathogenic Lep tospira spp. in blood from patients with culture-nega tive leptospirosis. BMC Infect Dis 2011 Dec 13;11:338. 25. Division of Communicable Diseases. Plague Manual: Epidemiology, Distribution, Surveillance and Con trol 1999. 26. Human Leptospirosis: Guidance for Diagno sis, Surveillance, and Control 27. Healy GR, Ruebush TK 2nd. Morphology of Babe sia microti in human blood smears. Am J Clin Pathol 1980;73(1):107-109. 28. currence of Orientia tsutsugamushi in small mammals from Thailand. Am J Trop Med Hyg 2003;69(5):519-524. 29. Rodkvamtook W, Gaywee J, Kanjanavanit S, et al. Scrub typhus outbreak, northern Thailand, 2006-2007. Emerg Infect Dis 2013;19(5):774-777. AUTHORS The following authors are with the Department of EntoDr Linsuwanon is the head, Scrub Typhus Section; Dr Krairojananan is the head, Leptospirosis Section; Mr Leepitakrat is the head, Mite and Rodent Section; MAJ Davidson is the Chief, Department of Entomology; MAJ Wanja is the Deputy Chief, Department of Entomology. Royal Thai Army-AFRIMS, Bangkok, Thailand.

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40 http://www.cs.amedd.army.mil/amedd_journal.aspx Throughout history, epidemics of infectious diseases of armies, causing delay and cancellation of military ployed preventive medicine for force protection in order the ratio of deaths due to disease versus battle injury was approximately 10:1, which decreased to 1:1 during World War I and 0.01:1 during the Gulf War. 1 During the American Revolution, the Continental Army was greatly Surgeon for General Washington, and ancestor of this tal Army against smallpox. 2 Today, the mission of the readiness by identifying and assessing current and emerging health threats, developing and communicat ing public health solutions, and assuring the quality and 3 Most emerging and reemerging disease threats to hu 4 prised 7.4% of all reportable medical events, excluding sexually transmitted diseases, with tick-borne diseases being the most frequently reported. 5 Mosquito-borne diseases, such as West Nile virus (WNV) and Zika vi rus, also pose a risk to military personnel and their fam ilies. For example, in 2015, 6% of Culex species pools were positive for WNV. 6 diseases continue to pose a risk to military personnel and their families, particularly where crowding or other unique stressors exist. 7 Biological agents are a threat to military installations through use of weapons, surreptitious attack, or crimi nal release. Bioagent databases have been developed for during natural outbreaks and criminal/terrorist release, the Biological Agents Database in Poland. The accuracy and applicability of these lists/databases can vary de pending on whether the application is military or civil ian. 8,9 (HPAC) is used by the Department of Defense for train ing, planning, and tactical operations, and has satisfac torily met the criteria for dispersion modeling. 10 The Bio agent Transport and Environmental Modeling System (BioTEMS) has been used to supplement HPAC to pro vide greater resolution should a weapon of mass destruc lease as well as low volume/low altitude/surreptitious re lease. For example, vertical resolution can be improved in HPAC for heights of 10 m or less. 11 In a collaborative study between the Defense Threat Reduction Agency Chemical Brigade; and the South Carolina Department of Health and Environmental Control, BioTEMS accu rately predicted environmental survival and transport of a simulated release, whereas HPAC underestimated environmental survival and transport by 300%.* The BioTEMS consists of a set of algorithms and models that have been used as a standalone system for risk as sessments of bioagents, infectious diseases, vectors, and to supplement HPAC. The BioTEMS has been used to produce bioagent risk assessments for an overseas na val installation, Fort Detrick, national and international training exercises, national political conventions, and to assist the DTRA during a presidential inauguration in ment of Biological Integrated Detection Systems (BIDS) units. Risk assessments have also been developed with and to distribution of vectors, eg, arboviruses, Ebola, Shigella tularemia, mosquitoes, ticks, and mites. It has been used to produce risk assessments in several coun Risk Assessment Mapping for Zoonoses, Bioagent Pathogens, and Vectors at Edgewood Area, Aberdeen Proving Ground, Maryland Thomas M. Kollars, Jr, PhD Jason W. Kollars Limited access documents not available to the general public.

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January June 2018 41 Recently, BioTEMS was used to identify free-living pathogenic amoebae as the most likely cryptic reser voirs for Ebola virus ( P >93%), identify high risk areas within 15 m, and to determine where to place ProVec tor devices with antimicrobials. 12 The BioTEMS Ebola model and ProVector anti-Ebola formulation have the potential to reduce the risk of Ebola virus for deployed military forces. Military personnel and their families can be at risk from vector-borne diseases and release of bioagents on mili tary installations. For example, high risk areas for Yer sinia pestis the etiologic agent of bubonic plague, were with some high risk sites adjacent to family housing on the base. 13 military personnel and their families where competent vectors are present. In 2015, over 1,000 ticks tested by the Army Public Health Command were positive for B. burgdorferi 21% of I. scapularis ticks were positive. 14 The Edgewood Area, Aberdeen Proving Ground (APG), notic/vector borne diseases and the release of a bioag ent. Through routine sampling of mosquito populations, unit at APG detected WNV positive mosquitoes and fol lowed up with mosquito control in 2014 15 ty from 2000 to 2015. 16 Preliminary modeling of I. scap ularis populations was accurate to within one square meter at the Edgewood Area. 17 Because of the potential bioagents, BioTEMS risk assessments were conducted (EEE), WNV, Zika virus (ZIKAV), unnamed Bioagent Amblyomma americanum ), and the black-legged tick ( I. scapularis ). METHODS AND RESULTS There are approximately 1,000 people living on Edge wood Area, with nearly 15,000 people working in both areas of APG. Nearly 20,000 retirees and their fami lies use the recreational facilities at Edgewood. 18 Ar cGIS geospatial analysis software, Statistica statisti geographic information and conduct data analysis. The BioTEMS uses up to several hundred abiotic and biotic factors to produce risk and vulnerability assessments for biological agents and infectious diseases. Examples of biotic and abiotic factors include pathogen strain, vector/host relationship, vectorial capacity, host/vector of hosts and vectors, soil, and weather conditions, such as wind, temperature, precipitation, and shade. The BioTEMS analysis includes mechanistic and empiri logic, niche analysis, random forests, general additive regression, and parametric and nonparametric statis tics. The BioTEMS is capable of identifying direction of movement of pathogens/vectors, areas for mitigation and management, time for optimal medical countermea sures, and sites for environmental sampling and optimi model was used to model ZIKAV. The TIGER acronym represents the 6 stages in the invasion of a mosquito spe cies or haplotype: and rate of transport to a locality. Introduction the point or area of initial introduc tion/immigration of species or haplotypes and pre liminary spread into a locality. Gap determines the area where vector/pathogen a foothold. Escalade incorporates abiotic and biotic factors as possible resistance to invasion. Residence and recruitment incorporates fac tors and areas where vector/pathogen adds to ge netic diversity or becomes endemic and recruits BioTEMS risk assessment maps (RAMs) were devel oped for Edgewood for the following infectious diseases Amblyomma ameri canum ), and black-legged tick ( Ixodes scapularis ). Both HPAC and BioTEMS were used to model the simulated release of the unnamed bioagent. The BioTEMS risk as sessment, based upon abiotic and biotic factors, is given nel at the Edgewood Area, with I. scapularis posing an 18% risk and A. americanum a 14% risk, for a combined risk assessment of 32%. The risk assessment of mosqui to-borne diseases at the Edgewood Area ranked WNV highest at 1.1% and EEE at 0.2%. The expected direction of movement of ZIKAV introduced through the airport is 349. The BioTEMS risk assessment for H5N1 Avian by HPAC which estimated its time to degradation at 24

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42 http://www.cs.amedd.army.mil/amedd_journal.aspx 8 km Figure 4 BioTEMS risk assessment map: eastern equine en cephalitis virus at the Edgewood Area. Red polygons indicate optimal sites for surveillance and integrated vector manage ment. N 5 km Figure 3 BioTEMS risk assessment map: West Nile virus at the Edgewood Area. Red polygons indicate optimal sites for surveil lance and integrated vector management. N 8 km Figure 2 BioTEMS risk assessment map: lone star tick ( Ambly omma americanum) at the Edgewood Area. Red polygons indi cate optimal sites for surveillance. N Figure 1 BioTEMS risk assessment map: black-legged tick ( Ixo des scapularis) at the Edgewood Area. Red polygons indicate optimal sites for surveillance. 8 km N RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS AT EDGEWOOD AREA, ABERDEEN PROVING GROUND, MARYLAND

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January June 2018 43 hours. The BioTEMS predicted the bioagent would last a minimum of 30 days in the environment and spread beyond the initial area of deposition. It also predicted the bioagent could replicate over 10,000 times the initial release amount, resulting in the environmental transport sampling for the vectors and pathogens (Figures 1-7). CO MM ENT Tick-borne Pathogens The following is a summary of several tick-borne patho gens detected in I. scapularis and A. americanum from North America as reported by the Centers for Disease Control and Prevention in 2018 19 : Anaplasmosis is transmitted to humans by tick bites pri marily from the blacklegged tick ( I. scapularis ) in the Babe sia microti ed States is transmitted by the blacklegged tick ( I. scap ularis ) and is found primarily in the northeast and upper midwest. Borrelia mayonii which also causes Lyme borreliosis, has been found in I. scapularis in the upper Borrelia miyamotoi trans mitted by I. scapularis is suspected of causing illness States and has been detected in A. americanum ; its dis is transmitted by A. americanum and Heartland virus found in the midwest and the south is most likely trans mitted by A. americanum Lyme disease is transmitted by I. scapularis in the eastern and upper midwestern Ixodes species, is the most commonly reported vector-borne ported annually, with case reports in Maryland ranking consistently among the top 10%. 15 Southern-tick associ ated rash illness is transmitted by A. americanum Tula remia is transmitted by the Dermacentor variabilis D. andersoni and A. americanum Powassan disease, most cases of which have been reported from the northeast and Great Lakes region, is transmitted by I. scapularis and the groundhog tick ( I. cookei ). Rocky Mountain spotted fever (RMSF) is transmitted by ( D. variabilis ), 8 km N Figure 5 BioTEMS risk assessment map: Zika virus if introduced through the airport located at Edgewood Area. Red polygon indicates high risk area for immediate integrated vector man agement and surveillance to reduce likelihood of introduction, yellow polygon indicates surveillance areas and control should Zika virus be detected, purple arrow indicates most likely direc tion of spread of Zika virus in mosquito population. 8 km N Figure 6 BioTEMS risk assessment map: H 5 N 1 at the Edgewood Area. Red polygons indicate optimal sites for environmental testing and surveillance in waterfowl.

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44 http://www.cs.amedd.army.mil/amedd_journal.aspx D. andersoni and the brown dog tick Rhipicephalus sanguineous Spotted-fever group Rickettsia have been isolated from A. americanum a species that is capable of transmitting RMSF in the lab, although its role in RMSF transmission is not well understood. 20 Also, an emerging illness, delayed anaphylaxis to red meat, is as sociated with A. americanum 21 In the November 2017 Vector-borne Disease Report, 22 the Army Public Health Center reported 71 cases of Lyme disease in active duty DoD Human Tick Testing Kit Program for B. burgdor feri 25% were positive; 7 of these ticks also tested posi tive for Babesia microti and 9 tested positive for Ana plasma phagocytophilum 22 Evidence from other stud ies indicate high risk from these 2 species in Maryland. Twenty-six percent of I. scapularis in Carroll, Harford, and Howard counties tested positive for B. burgdorferi, and and B. lonestari have been isolated from A. americanum at Aberdeen Proving Ground. 23-25 West Nile Virus 26 West Nile virus is an arbovirus, principally transmitted by mosquitoes in the genus Culex with passerine birds serving as the natural reservoir. Transmission to humans, horses, and other mammal species occurs through a bridge mosqui to species, such as Cx. salinarius, Cx. pipiens and Cx. restuans ed States. 27 WNV in Maryland was reported in 2001, and from 2001 and 2016 there were 334 reported cases. 28 In addition to Culex species, Ochlerotatus japonicas, an invasive spe cies in Maryland, is capable of transmitting WNV. 29 In addition to Culex species, monitoring for and testing of Oc. japonicas and Ae. albopictus should be conducted at the Edgewood Area. The BioTEMS predicted the risk of EEE to be low at the Edgewood Area. From 20072016 there were no reported cases of EEE in humans in Maryland; however, there have been EEE cases report ed in horses and in mosquitoes, for example, Culiseta melanura and Culex salinarius. 30,31 The BioTEMS has been used to predict EEE in other states and is capable of predicting the risk of EEE geographically to within 30 m. 32 Surveillance of EEE at Edgewood Area should be conducted when testing for arboviruses in other mos quito species, such as WNV C. pipiens or when EEE is reported in other parts of Maryland. Zika Virus caque monkey and in 1948 from Aedes africanus from cages placed on a tower in the Zika Forest near Lake 33 The Zika Forest is a tropical forest, now surrounded by pastures and with small hamlets where research continues on vector-borne diseases, even using the same tower (Figure 8). However, ZIKAV is no longer restricted to transmission of Ae. africanus in the tropical forest ecosystem in Africa. Several Aedes species have now been implicated in transmission of ZI KAV to humans in urban habitats where the poor are particularly at risk and the disease is spreading global ly. 34 Establishing patterns of invasion of vectors and vec tor-borne diseases into new geographic areas is critical for protecting the public health and nave human popula tions. For example, the predictive map developed for Ae. aegypti and Ae. albopictus globally has a resolution of 5 km. 35 The principle factor responsible for the introduc tion of disease vectors is air and ship transport. 36,37 Edge wood Area has a small airport, and aircraft travelling from areas within the North America or other regions could introduce infected Aedes species infected with quito species can spread rapidly across regions through ground transport. 38,39 In addition to the import of infect ed mosquitoes, introduction of ZIKAV into the a new 4 km Figure 7 BioTEMS risk assessment map: Bioagent X if released at Edgewood Area. Red polygons indicate optimal sites for sur veillance and environmental transport and a yellow ellipse indi cates HPAC deposition model of Bioagent X. N RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS AT EDGEWOOD AREA, ABERDEEN PROVING GROUND, MARYLAND

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January June 2018 45 geographic area can occur when local mosqui toes bite infected travelers and become infected or when people become infected through sex or contaminated blood. 40,41 The BioTEMS TIGER model has been used and validated to identify areas at high risk for invasive mosquito species and mosquito-borne diseases, and identify sur veillance and integrated vector management in several countries. It is able to predict direction of movement to within 4 or less. 42 From 2016 through May 2017, nearly 4,000 cases with laboratory evidence of recent possible Zika in 43 As frequent travelers, military personnel and their families are at risk for arbovirus infection and transporting infected mosquitoes or introduc ing infection to local mosquitoes upon return. Pre-travel counseling should be provided to travelers to ZIKAV-outbreak regions. 44 H 5 N 1 Avian Influenza There are several sites where the virus could be maintained and serve as a source of an outbreak should it be introduced. Environmental trans mission can provide a mechanism for the persis epidemics cannot be sustained. 45 In a study of yard poultry was positively associated with ex posure to waterfowl and location, particularly in northern Maryland. 46 Edgewood Area lies on a peninsula waterfowl should be of concern. Environmental samples at the Edgewood Area. Because of the large area suitable for waterfowl, identifying areas at highest risk for the Bioagent X The threat of biological warfare and bioterrorism is sig be easily concealed, transported, and released into sus ceptible populations. Military and civilian populations provide adequate protection. 47 The BioTEMS was used in conjunction with HPAC to model a computer simu HPAC to accurately predict the environmental survival and transport of the bioagent. For example, HPAC pre restricted in area, whereas BioTEMS predicted the bio agent would survive a minimum of 30 days and would The BioTEMS can also be used to identify where envi ronmental samples can be collected for both measuring naturally occurring strains of bioagents and sampling post-release. This capability can assist in consequence management and providing forensic information for law enforcement. CONCLUSION Identifying the risk of vector-borne diseases and imple menting integrated vector management at the Edgewood is determined, medical and preventive measures can be taken to reduce the threat to military personnel and their families. For example, several high risk sites were adjacent to base family housing located in the northeast Figure 8 Research tower in the Zika forest and surrounding landscape near Lake Victoria, Uganda. A mosquito vector for the Zika virus, Aedes africanus 1948.

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46 http://www.cs.amedd.army.mil/amedd_journal.aspx management in and around this family housing area, including education, surveillance, testing, vegetation management, and, if needed, application of pesticides. To reduce time and cost of surveillance, sites for sur veillance that overlap can be chosen. Although not uti to identify where biological sensors should be placed at mental survival. Additional BioTEMS RAMs are being developed for other military installations and cities in REFERENCES 1. tious diseases on war. Infect Dis Clin North Am 2004;18:341-368. 2. Gibson J. Dr. Bodo Otto and the Medical Back ground of the American Revolution Baltimore, MD: Charles C. Thomas; 1937. 3. net]. Available at: https://www.army.mil/info/orga usaphc#org-about. Accessed February 26, 2018. 4. Dorjee S, Poljak Z, Revie CW, Bridgland J, McNab Zoonoses Public Health 2013;60(6):383-411. 5. Vol 5, 1 January-31 December 2014:2. Available at: https://phc.amedd.army.mil/Periodical%20Li brary/ZoonoticDiseaseSummary_Vol5_2015.pdf. Accessed June 7, 2018. 6. Vol 6, 1 January-31 December 2015:2. Available at: https://phc.amedd.army.mil/Periodical%20Library /ZDR_CY2015_v2.pdf. Accessed June 7, 2018. 7. Gray GC, Callahan JD, Hawksworth AW, Fisher military personnel: countering emerging threats. Emerg Infect Dis 1999;5:379-385. 8. M. Biological agents database in the armed forces Arch Immunol Ther Exp (Warsz) 2014;62:357-361. 9. Cieslak TJ, Kortepeter MG, Wojtyk RJ, JansenHJ, proposed methodology for assessing future bio weapon threats. Mil Med 2018;183:E59-E65. 10. pability (HPAC) Dispersion Model. J App Meteo rol 2005;44:495-501. Available at: https://journals. ametsoc.org/doi/full/10.1175/JAM2205.1. Accessed June 6, 2018. 11. Hanna SR, Reen B, Hendrick E, et al. Compari son of observed, MM5 and WRF-NMM modelsimulated, and HPAC-assumed boundary-layer meteorological variables for 3 days during the Boundary-Layer Meteo rol 2010;134(2):285-306. Available at: https://link. springer.com/article/10.1007/s10546-009-9446-7. Accessed June 6, 2018. 12. Kollars TM Jr, Senessie C, Sunderland G. Iden tifying and modeling the cryptic reservoirs of Afr J Clin Exp Microbiol. 2018;19(3):229-237. Available at: https://www.ajol.info/index.php/ajcem/article/ view/172666/162067. Accessed June 29, 2018. 13. Air Force Academy: identifying areas at risk for the persistence of plague using the Bioagent Transport and Environmental Modeling System (BioTEMS). J Microbiol Modern Techniques 2017;3(1):1-3. Available at: http://www.annexpublishers.co/arti Identifying-Areas-at-Risk-for-the-Persistence-ofPlague-using-the-Bioagent-Transport-and-Envi ronmental-Modeling-System-BioTEMS.pdf. Ac cessed June 7, 2018. 14. Borne Disease Report; 9 September 2015. Avail able at: https://phc.amedd.army.mil/Periodical%20 Library/Vector-borneDisease9SEP2015.pdf. Ac cessed June 7, 2018. 15. Rominiecki A. APG continues mosquito testing for West Nile virus. September 11, 2014. APG News Aberdeen Proving Ground, Maryland. 16. Centers for Disease Control and Prevention. Lyme Disease [internet]. 2018. Available at: https://www. cdc.gov/lyme/index.html. Accessed June 7, 2018. 17. Kollars TM. Habitat modeling of the black-legged tick: reducing the risk of lyme disease at a mili Curr Trends Bioeng Biomed Sci 2018;12(2):1-2. Available at: https://juniperpublishers.com/ctbeb/pdf/CTBEB. MS.ID.555834.pdf. Accessed June 7, 2018. 18. Agency for Toxic Substances and Disease Regis try. Public Health Assessment for US Army Aber deen Proving Ground, Edgewood Area Aberdeen, Harford County, Maryland Health and Human Services. May 20, 2008. Avail able at: https://www.atsdr.cdc.gov/hac/pha/aber pha052008.pdf. Accessed June 7, 2018. 19. Centers for Disease Control and Prevention. Tick Available at: https://www.cdc.gov/ticks/diseases/ index.html. Accessed June 7, 2018. 20. Parker RR, Philip CB, Jellison WL. Rocky Moun tain Spotted Fever: potentialities of tick transmis sion in relation to geographical occurrence in the Am J Trop Med Hyg 1933;13:341-378. RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS AT EDGEWOOD AREA, ABERDEEN PROVING GROUND, MARYLAND

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January June 2018 47 21. Commins SP, Platts-Mills TAE. Delayed anaphy Galactose alpha-1,3-Galactose (alpha-gal). Curr Allergy Asthma Rep 2013;13(1):72-77. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3545071/. Accessed June 7, 2018. 22. Vector Borne Disease Report; 20 November 2017. Available at: https://phc.amedd.army.mil/Periodi pdf. Accessed June 5, 2018. 23. Feldman KA, Connally NP, Hojgaard A, Jones EH, White JL, Hinckley AF. Abundance and infection rates of Ixodes scapularis nymphs collected from residential properties in Lyme disease-endemic areas of Connecticut, Maryland, and New York. J Vector Ecol 2015;40:198-201. 24. Stromdahl EY Randolph MP , Gutier rlichieae) infection in Amblyomma americanum (Acari: Ixodidae) at Aberdeen Proving Ground, Maryland. J Med Entomol 2000;37:349-356. 25. Stromdahl EY, Williamson PC, Kollars TM Jr, Evans SR, Barry RK, Vince MA, Dobbs NA. Evi dence of Borrelia lonestari DNA in Amblyomma americanum (Acari: Ixodidae) removed from hu mans. J Clin Microbiol 2003;41:5557-5562. 26. Centers for Disease Control and Prevention. York, 1999. MMWR Morb Mortal Wkly Rep 1999;48(38):845-849. 27. Molaei G, Andreadis TG, Armstrong PM, Ander son JF, Vossbrinck CR. Host feeding patterns of Culex mosquitoes and West Nile virus transmis Emerg Infect Dis 2006;12:468-474. 28. Centers for Disease Control and Prevention. West Nile virus disease cases reported to CDC by state of residence, 1999-2016 [internet]. 2017. Available at: https://www.cdc.gov/westnile/resources/pdfs/ data/West-Nile-virus-disease-cases-reported-toCDC-by-state_1999-2016_09292017.pdf. Accessed June 7, 2018. 29. in Frederick County Maryland: discovery, distribu tion, and vector competence for West Nile virus. J Am Mosq Control Assoc 2001;17(2):137-141. 30. Maryland Department of Health (2013). Eastern [internet]. August 16, 2013. Available at: https:// health.maryland.gov/newsroom/Pages/EasternEquine-Encephalitis-Confirmed-in-MarylandHorse.aspx. Accessed June 7, 2018. 31. Muul I, Johnson BK, Harrison BA. Ecological Studies of Culiseta melanura (Diptera: Culicidae) in relation to eastern and western equine encepha lomyelitis viruses on the eastern shore of Maryland. J Med Entomol 1975;11:739-748. 32. lance sites at maritime and airports to reduce the risk of export of eastern equine encephalitis and import of Zika viruses into coastal Georgia. IOSR J Dent Med Sci 2016;15:87-90. 33. Dick GW, Kitchen SF, Haddow AJ. Zika virus. I. Trans R Soc Trop Med Hyg 1952;46:509-520. 34. rus disease: a current review of the literature. Infec tion 2016;44(6):695-705. 35. al distribution of the arbovirus vectors Aedes ae gypti and Ae albopictus ELife eLife.08347. 36. 2006;103(16):6242-6247. 37. Meyerson L, Mooney H. Invasive alien spe Front Ecol Env 2007;5:199-208. 38. Lindsay MD, Jardine A, Giele C, et al. Investi acquired in Western Australia in seven decades: evidence of importation of infected mosquitoes?. PLoS Negl Trop Dis 2015; 9(9): e0004114. 39. V, Hendrickx G, Zeller H, Van Bortel W. A review of the invasive mosquitoes in Europe: ecology, pub lic health risks, and control options. Vector Borne Zoonotic Dis 2012;12(6):435-447. 40. Hills SL, Russell K, Hennessey M, Williams C, Zika virus through sexual contact with travelers ed States, 2016. MMWR Morb Mortal Wkly Rep 2016;65(8):215-216. 41. Musso D, Stramer SL. Zika virus: a new challenge for blood transfusion. Lancet 2016;387:1993-1994 42. Kollars TM. Potential for the invasive species Ae des albopictus and arboviral transmission through the Chabahar Port in Iran. Iranian J Med Sci 2017;S.1. 43. Centers for Disease Control and Prevention. Preg nancy outcomes after maternal Zika virus infec 1, 2016-April 25, 2017. MMWR Morb Mortal Wkly Rep 2017;66(23);615-621.

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48 http://www.cs.amedd.army.mil/amedd_journal.aspx 44. Lindholm DA, Myers T, Widjaja S, et al. Travelers are at risk for arbovirus infection; pretravel coun seling should be provided to travelers to ZIKV-out break regions. Am J Trop Med Hyg 2017;96:903-912. 45. Breban R, Drake JM, Stallknecht DE, Rohani P. The role of environmental transmission in recur PLoS Comput Biol 2009;5(4):e1000346. 46. Madsen JM, Zimmermann NG, Timmons J, Tablante NL. biosecurity risk factors in Maryland backyard poultry: a cross-sectional study. PLoS ONE 2013; 8(2):e56851. 47. Atlas RM. Combating the threat of biowarfare and bioterrorism: defending against biological weapons is critical to global security. BioSci ence .1999;49(6):465-477. Available at: https://aca demic.oup.com/bioscience/article/49/6/465/229529. Accessed June 7, 2018. AUTHORS Dr Thomas Kollars is with the College of Health Sci former Brigade Surgeon of the 415th Chemical Brigade Mr Jason Kollars is a senior in the College of Engi Statesboro, Georgia. RISK ASSESSMENT MAPPING FOR ZOONOSES, BIOAGENT PATHOGENS, AND VECTORS AT EDGEWOOD AREA, ABERDEEN PROVING GROUND, MARYLAND

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January June 2018 49 There are various, disparate resources of information available for consultation regarding potential biological risks associated with various parts of the world; how ever, there is not a consolidated resource of information preventive measures and diagnostic tests that should be performed to identify overt as well as subclinical infec tion. This article in intended to provide a consolidated diagnostic testing, and prevention of diseases that pose a risk to military service members. The information is presented to assist medical providers with accessing information needed to best determine preand postde ployment medical assessment for preventive medicine and veterinary personnel, and other service members vector-borne diseases. cation and descriptions of many resources that provide agnosis. Additionally, resources to inform medical read iness and prepare the medical threat brief are provided. es faced by an Army Reserve unit in achieving missionSCENARIO: MISSIONSPECIFIC MEDICAL THREAT READINESS CONSIDERATIONS DET 22 is preparing for deployment to Eritrea. The DET Commander, a physician, has requested her Pre threat brief outlining the known and potential biologi cal threats that may be encountered during deployment. who provides assistance with preparation of the medical agnostics beyond the scope of what can be supported in theater, and individual medical readiness including: personal protective measures, serology testing, challenges in ensuring the information is as current and complete as possible. First, she must determine if there is current information available on the known and poten tial biological threats in Eritrea. Does the Army Public Health Center have a prepared Entomological and Zoo the next 6 weeks? Also, whom should she contact for as for the medical threat brief core and redeployment slides? Optimizing Mission-Specific Medical Threat Readiness and Preventive Medicine for Service Members ABSTRACT 'HSOR\)-25.9 (PHQWV\003DQG\003PRELOL]DWLRQV\003RI\003$UP\\000ROGLHUV\003KDYH\003EHHQ\003FRQWLQXLQJ\003SURFHVVHV\003DQG\003ZLOO\003EH\003VXVWDLQDEOH\003UH quirements for the foreseeable future. Global deployments often position service members in austere environ Reserve units and units that do not have access to preventive medicine advisors. With the expanding list of known pathogens and the discovery and surveillance of emerging threats, it is extremely important for leaders This article discusses the resources that are available to leaders, providers, and service members, and provides

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50 http://www.cs.amedd.army.mil/amedd_journal.aspx The detachment will require the ability to integrate re sources available that provide global biosurveillance, medical readiness, diagnostics, and preventive medicine information. mation needed and compile them into one resource to provide to the command? The health of the service members depends on the availability of accurate, cur rent information. the information needed by the Soldiers and leaders dur ing this deployment preparation, especially since many of the Soldiers will venture into austere environments, and may work routinely with potential vectors of dis ease. Does the information adequately deliver/provide the Soldiers and medical providers with information that will support the mission? PROBLE M STATE M ENT How do those responsible for medical readiness of de ploying Army units obtain current information on bio logical threats across the range of military operations, with the variety of exposure to pathogens and in the aus tere environments in which they serve? WHAT IS ADEQUATE MEDICAL READINESS FOR DEPLOY M ENT? Many resources are available for consultation by Sol diers who are deploying to areas of operation that pose medical risks. The evolution of known and emerging pathogens warrants the availability of a contemporane ous resource of information for deploying troops who have the potential to be exposed to pathogens that have riety of natural and induced processes. Additional varia tion can also occur through migration from other popu lations of a pathogen, or through a range of cytological and molecular changes. These processes warrant con stant vigilance and surveillance of known and emerging pathogens. Preventive Medicine (PM) and Veterinary Corps (VC) Soldiers bear the risk of exposure to vectors and patho gens that are otherwise of little concern to military ser vice members. The interaction with foreign food sourc es, animals, and austere environments are a frequent occurrence for PM and VC Soldiers, and exposes them INFOR M ATION SOURCES World Health Organization on international travel and health, global vector-borne diseases, and information concerning disease outbreak distribution maps. This information is available at http:// www.who.int/en/. US Army Public Health Center be a world-class provider of public health services across Its mission is to enhance Army readiness by identify ing and assessing current and emerging health threats, developing and communicating public health solutions, public health enterprise. The APHC is an exceptional resource for information that includes major disciplines of concern to deploying service members. These include: animal medicine, deployment and environmental health, diseases and conditions, health surveillance and evaluation, laboratory sciences and toxicology, and The APHC website is a primary site for information on global threats and best practices to promote health and prevent disease. The website is available at https://phc. amedd.army.mil. National Center for Medical Intelligence The National Center for Medical Intelligence (NCMI) is a component of the Defense Intelligence Agency. Its mission is to monitor, track, and assess a full range of troops are deployed to foreign areas for combat, peace keeping, or humanitarian operations, NCMIs assess ment of potential health risks and foreign health care capabilities assists medical providers in planning for the proper medical countermeasures, health care support, and medical personnel support. Environmental health: identify and assess envi ronmental risks that can degrade force health or OPTIMIZING MISSION-SPECIFIC MEDICAL THREAT READINESS AND PREVENTIVE MEDICINE FOR SERVICE MEMBERS

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January June 2018 51 Infectious disease: identify, assess, and report on infectious disease risks that can degrade mission term health implications, and support national se curity and homeland defense by reporting foreign disease outbreaks that may be naturally occurring or intentional. Life sciences and biotechnology: assess foreign bio technological developments and medical advances. Medical capabilities: assess foreign emergency and disaster response capabilities, and maintain and update an integrated database on all medical treat ment, training, pharmaceutical, and research and production facilities. Medical intelligence products. The NCMI resources are available at https://www.ncmi. detrick.army.mil/index.php. SPECIFIC RESOURCES Entomological and Zoonotic Operational Risk Assessments Entomological Sciences Program and the Veterinary Services Portfolio to assist public health and military medical planners with predeployment planning and de ployments to a country of concern. In addition to vec risks to military personnel and military working dogs. as well as health risk communication consultation and training. It is available at https://phc.amedd.army.mil/ Epidemiology and Surveillance Global Emerging Infections Surveillance and Response System The Defense Health Agency (DHA) Armed Forces Health Surveillance Branch (AFHSB) plays a critical role in force health protection. As the central epidemio ducts medical surveillance to protect all those who serve our nation in uniform and allies who are critical to our national security interests. The AFHSB collects data about service members and populations of our global partners. The Global Emerging Infections Surveillance and Response System (GEIS) has become a respected authority in surveillance and research about emerging infectious disease and endemic diseases throughout the world. The AFHSB-GEIS provides direction, funding, and oversight to a network of more than 70 partners based in all regions of the world. Working in conjunc tion with their host nations, these partners conduct dis ease surveillance and rapid outbreak response, encour age research and innovation, and build capacity. The GEIS partner network enhances global public health capacity by providing support to: Improve DoD and international partners capac ity to detect and respond to outbreaks of relevant emerging infectious disease. Promote the establishment of electronic surveil lance systems that support comprehensive emerg ing infectious disease surveillance and/or syndrom ic-based surveillance systems such as the Suite for Automated Global Electronic bioSurveillance. and new surveillance and outbreak response systems. Support applied research and development of labo ratory diagnostic technologies to rapidly detect po tential emerging infectious disease threats (eg, diag nostics, computers and/or laboratory-based systems). Enhance the host nation public health research, clinical investigation and laboratory capacity. The AFHSB can access epidemiologic information and service member exposure data, and it produces monthly and annual reports on disease occurrence and outcomes. The resources of the AFHSB are available at https:// www.afhsc.mil/Home/About. Disease Reporting System Internet The Disease Reporting System Internet (DRSi) is an in ternet-based resource used to report and keep a histori cal record of reportable medical events (RME), and a the incidence of any disease of interest. The DRSi was launched by the Navy and Marine Corps Public Health Center in 2008 and is the system now used by both the Navy and Army for reportable diseases. It uses guide ployed are required to use DRSi to report RMEs. The Army Disease Reporting System Internet is the Armys branch of DRSi. Access is restricted to medical pro fessionals who have been granted access in order to perform disease reporting or surveillance. Reportable ing the DRSi access request process are available at the Public Health Centers website, https://phc.amedd.army. mil/topics/healthsurv/de/Pages/DRSiResources.aspx. Global Biosurveillance Portal The Global Biosurveillance Portal (G-BSP) was devel

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52 http://www.cs.amedd.army.mil/amedd_journal.aspx Chemical and Biological Defense to meet requirements for biosurveillance situational awareness and collabo ration capability to support strategic, operational, and enterprise environment that facilitates collaboration, communication, and information sharing in support of the detection, management, and mitigation of manProvides a set of tools and capabilities to enhance tactical to the strategic level. mation sources. Hundreds of data sources can be displayed as layers on a map, enabling users to re Provides a one stop shop to access information on countermeasures; facilities capable of providing in terventions; and local infrastructure and resourcing. This resource is accessible by establishing an account at https://www.biosurveillanceportal.org. APHC Entomological Sciences Branch gional Commands, The Entomological Sciences Branch maintains the expertise to address vector-borne, emerg readiness. Services include: Vector and reservoir surveillance: assists units with setting up surveillance programs for insects and arthropods capable of transmitting disease, and assess pathogen levels in large and small mammal populations on military installations. insects, rodents, reptiles, birds, nuisance plants, or any other unknown specimen. Pathogen diagnostics: coordinates the testing of in sects, arthropods, animal blood, and tissue, as well as environmental samples for a wide range of dis ease causing organisms. Installation medical entomology and public health support: reviews/creates documents and program activities to bring pest management programs into compliance with regulatory requirements and sound integrated pest management practices. other educational material on operational and insti notic disease. Deployment training: provides training on entomo logical issues of preventive medicine for units pre paring to deploy. Special consultations and tailored training: subject matter experts who can perform quick-response investigations and training on entomology-related procedures, practices, or perceived issues. ences Branch are available at https://phc.amedd.army. mil/topics/envirohealth/epm/Pages/Deployment-PestManagement.aspx. There are also external resource nids and venomous snakes, which are prevalent in the areas of operation where service members are frequent ly deployed. Diagnostics US Army Medical Research Institute of Infectious Diseases tory for medical biological defense research. It serves as infectious disease agents and is a DoD reference center for information related to arthropod-borne and hemor rhagic fever viruses. While their core mission is to pro vestigate disease outbreaks and threats to public health. solutionstherapeutics, vaccines, diagnostics, and in Development, testing and evaluation of medical countermeasures. Providing world-class expertise in medical biologi cal defense. Training and educating the force. Maintaining biosafety, biosurety and biosecurity standards. Preparing for technological uncertainty. gens laboratory where clinical or environmental sam guidelines on sample submission. More information is available at http://www.usamriid.army.mil/index.htm. OPTIMIZING MISSION-SPECIFIC MEDICAL THREAT READINESS AND PREVENTIVE MEDICINE FOR SERVICE MEMBERS

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January June 2018 53 Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) Division of Vector-Borne Diseases maintains The Inter national Catalog of Arboviruses. The Catalog is meant primarily for the description of those viruses biologi cally transmitted by arthropods in nature and actually or potentially infectious for humans or domestic ani mals. The Catalog lists, describes, and provides techni cal information for hundreds of viruses, including the epidemiology and geographic distribution, and provides through state health departments. Instructions for sub mitting specimens to CDC Diagnostic Laboratories for EZORA Website mation about environmental sample submission, avail ability of Arthropod Vector Rapid Detection kits, food and bottled water analysis, toxicology assessments, and other evaluations. Prevention Centers for Disease Control and Prevention The CDC maintains a website on global travelers health that includes information for clinicians regarding medi cines and vaccinations that should be administered prior to travel, as well as posttravel evaluation guidance. The CDC Health Information for International Travel (com monly called the Yellow Book) is published every 2 years as a reference for those who advise international travel ers about health risks. This reference is available at http:// wwwnc.cdc.gov/travel/page/yellowbook-home-2014. Immunizations and Chemoprophylaxis Army Regulation 40-562 1 nations for military personnel by category, along with guidance on pre-exposure rabies prophylaxis for at-risk populations. Chemoprophylaxis for diseases that have cal disease, leptospirosis, plague, scrub typhus, small pox, travelers diarrhea, and malaria. Consulting for cur rent information and guidance for appropriate drugs and dosing regimens is essential (for example, the CDC Ad ), the NCMI, and the Control of Communicable Diseases Manual 2 ). Note that the recommendation to consult with the appropriate preventive medicine authority has been omitted from the current (2013) version of Army Regula tion 40-562 DHA Immunization Healthcare Branch consultative services, educational support, and train ing resources. Its resources are available at https:// health.mil/Military-Health-Topics/Health-Readiness/ Rabies Prophylaxis ians and animal care providers are found in the Compen dium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel 3 The docu ment addresses preand postexposure prophylaxis as well as titers, and promotes its guidelines in accordance with the CDC ACIP. http://www.cdc.gov/vaccines/acip/ about.html. Regulatory Guidance Army Personnel Policy The Department of the Army Personnel Policy Guidance for Overseas Contingency Operations 4 requires that all personnel deploying to an area of operations are current in a table format. Further, the policy mandates that in accordance with ASD(HA) Memorandum dated March 14, 2006, 5 predeployment serum specimens for medical examinations will routinely be collected within one year of deployment. However, if an individuals health status has recently changed or has had an alteration in occupa tional exposures that increases health risks, a healthcare provider may choose to have a specimen drawn closer to the actual date of deployment. Postdeployment serum specimens for medical examinations should be collect tion site, home station, or inpatient medical treatment facility. Active duty military activities with medical facilities are usually able to perform some diagnostic testing in ten referred to approved laboratories or other military installations. Geographic Combatant Command Medical Entry Standards policies. Additionally, to deploy to a given combatant command area of responsibility, additional standards may apply based upon operational conditions of the

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54 http://www.cs.amedd.army.mil/amedd_journal.aspx Central Command Individual Protection and Individual/ Each combatant command develops its own standards command. Leaders of deploying service members must ness policies that pertain to its area of responsibility. Medical Threat Briefing health guides, and deployment health cards is to help reduce the risk of disease and nonbattle injury during deployment. Per the Army Personnel Policy Guidance, 4 be administered and distributed by preventive medicine personnel. on health threats and countermeasures while deployed. A MTB resources website is hosted on Army Knowl should use the core slides as a starting point to custom CONCLUSION Although we will continue to face known and emerg ing biological threats globally, the Army is able to meet the future challenges of health promotion and medical readiness. With the vast array of resources available for consultation, the challenges of surveillance, diagnostics, of operating in austere environments while maintaining exchange of updated methodologies that support ad and personnel protection. REFERENCES 1. Army Regulation 40-562 Im munizations and Chemoprophylaxis Washington, DC: Departments of the Army, Navy, Air Force, and Coast Guard; 2013. Available at: https://army pubs.army.mil/epubs/DR_pubs/DR_a/pdf/web/ r40_562.pdf. 2. Heyman DL, ed. Control of Communicable Dis eases Manual 20th ed. Washington, DC: American Public Health Association Press; 2014. 3. Williams CJ, Scheftel JM, Elchos BL, Hopkins SG, Levine JF. Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel: National Association of State Public Health Veterinarians: Veterinary Infection Control Committee 2015. J Am Vet Med Assoc 2015;247(11):1252-1277. Available at: https://avma journals.avma.org/doi/10.2460/javma.247.11.1252. 4. Department of the Army Personnel Policy Guid ance for Overseas Contingency Operations Wash 5. Memorandum: Policy for Preand Post-deploy partment of Defense; March 14, 2006. Available at: http://www.armyg1.army.mil/MilitaryPersonnel/ dtd%2020060314.pdf. AUTHOR gade, Devens, Massachusetts. OPTIMIZING MISSION-SPECIFIC MEDICAL THREAT READINESS AND PREVENTIVE MEDICINE FOR SERVICE MEMBERS Internal military document not readily accessible by the general public.

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January June 2018 55 Mumps is an acute viral disease caused by a para myxovirus that presents with fever and swelling of one or more of the salivary glands: parotid, sublingual, or submandibular. 1 Mumps is usually a self-limited, mild disease. However, in some cases, it can develop more se vere complications such as meningoencephalitis, or or chitis that results in male sterility. 2 Severe complications are typically more associated with patients who develop disease as adolescents or adults. 2 Mumps had become relatively rare in the post-vaccine era. 3 However, focal outbreaks have become increasingly common, particu and universities. 3 Mumps has an incubation period of 12 to 25 days following exposure, and can be transmitted to another person from roughly 2 days prior to symp tom onset until about 5 days after symptom onset. 4 The measles, mumps, and rubella (MMR) vaccine is only standard 2-dose series. 3 However, it is well-described that outbreaks have occurred even among populations where more than 85% of those at risk had received 2 doses of MMR vaccine previously. 3 the Centers for Disease Control and Prevention (CDC) advised that a 3rd booster dose of MMR vaccine be provided to a group or population at increased risk for acquiring mumps because of an outbreak. 5 How for postexposure prophylaxis, and in at least one small study, a 3rd dose given as postexposure prophylaxis was when compared to those exposed individuals who had previously received 2 doses of MMR vaccine. 6 BACKGROUND In spring 2018, the Fort Campbell Department of Pre suspected mumps cases who presented to the medical activity (MEDDAC) emergency department (ED) on a Friday afternoon (Day 0). The 3 suspected cases in volved an active duty Soldier (father, 29 years old), his spouse (mother, 29 years old), and their daughter (5 years old). The Soldier and his spouse reported the on set of fever and left facial swelling within the 24 hours prior to presentation to the ED (Day 1). The child had no overt facial swelling, but complained of jaw pain and tenderness. The Soldier reported that his family had an active mumps outbreak, staying from about 5 weeks prior to presentation to 2 weeks prior to presentation. The location to which the Soldier and his family traveled is not provided here due to privacy concerns. The Sol dier reported that his family stayed with members of his spouses family, and that all 4 members of his spouses cases of mumps while the Soldiers family was present. The Soldier stated that, in fact, he had moved his family to another house in an attempt to prevent transmission of mumps to his family. The Soldier initially felt that he and his family had gotten lucky as it had been over 2 weeks since their last contact with a known mumps case, and they had not yet developed symptoms. A review of available records found that the Soldier had received 2 doses of MMR vaccine at the time of his ac cession into the Army. His spouse had no evidence of Public Health Response to Imported Mumps CasesFort Campbell, Kentucky, 2018 ABSTRACT Mumps is an acute viral disease caused by a paramyxovirus that presents with fever and swelling of one or more of the salivary glands. Although not generally considered a disease of military importance, mumps has been associated with outbreaks among young adults in close living quarters, potentially placing Soldiers at risk for transmission of mumps when living in congregated settings. This article reports a recent public health response to 3 imported mumps cases occurring at Fort Campbell, Kentucky, that resulted in a contact inves highlights the need for continuous preparation for public health emergency response, and the need to develop and maintain strong working relationships with local civilian public health assets, as well as with installation

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56 http://www.cs.amedd.army.mil/amedd_journal.aspx MMR vaccine or mumps titer in her military electronic health record. The daughter had received a single dose of MMR vaccine, approximately one year prior. With further questioning, the Soldier revealed that he had (Day 1) prior to presentation, and that he slept in a communal tent with roughly 20 other Soldiers during this exercise. He also reported that his daughter attend ed an on-post elementary school for the 4 days prior to mumps, and reported epidemiologic linkage to known cases of mumps associated with a well-reported mumps outbreak, a contact investigation was initiated. INVESTIGATION The investigation began with a call to local civilian pub lic health authorities to request assistance with obtaining buccal swab mumps polymerase chain reaction (PCR) health authorities were very receptive to this request for assistance and immediately began coordination for testing. Buccal swab samples were obtained from the ratory. The samples were obtained in accordance with published CDC guidance. 7 These samples were collect buccal swab samples for mumps viral culture had been obtained during the familys ED visit for processing at a commercial laboratory. However, the presumed turn around time was excessive, and we could not be certain that the samples had been properly obtained. PCR in both the Soldier and his spouse. Mumps PCR was negative for the child; however, a serum mumps IgM returned positive for the child later on Day 6. Se rum mumps IgM is known to result in both false-posi tive and false-negative results in previously vaccinated individuals. 4 Thus, this positive mumps IgM may have been secondary to the child having received one dose of MMR vaccine previously. However, given the childs repeated exposures to known mumps cases among her family, and the risk of initially overlooking any second ary cases among other exposed children if we assumed the child to not be infected and therefore cease any fur ther investigation of the childs contacts, FTCKY DPM made the decision to continue the contact investigation as if the child represented a probable case, in accordance via PCR or viral culture in a patient with an acute illness acute parotitis or other salivary gland swelling lasting at least 2 days in a person with an epidemiologic link with a positive mumps serum IgM. 3,4 For the purposes of this investigation, presumptive evidence of mumps 2 doses of MMR vaccine for contacts over age 4 years, or laboratory evidence of immunity by positive mumps IgG serology, referred to hereafter as mumps titer. 3 All individuals involved in this investigation were born after 1957; thus, presumptive immunity based on age was not a consideration. (children and educators, healthcare workers, and other Soldiers). However, our contact and containment plan was generally consistent with the following recommen dations for each setting: (1) those contacts for whom evidence of presumptive immunity was available could continue attending work and school without interrup tion; (2) those contacts who had only received one dose of MMR should receive the second dose as soon as pos and (3) those contacts for whom no evidence of immu nity could be found were to be excluded from work and/ or school from postexposure day 12 through postexpo not provide complete immunity to all even after 2 doses, all contacts were reassessed for symptoms by question naire or interview on days 15, 20, and 26 following their respective exposure. Soldiers who had slept in the communal tent with the case-Soldier were considered close contacts. A list of these contacts was obtained through the case-Soldiers only 4 Soldiers had presumptive evidence of immunity available in the electronic medical record. This was in sumed to be present based on positive testing of measles and rubella titers drawn upon a Soldiers accession into the Army. 8,9 This assumption then transfers to the elec tronic medical record as the Soldier being up to date on MMR vaccine. However, this assumption was not consistent with published guidance for contact investi gations. 3,4 Thus, as only measles and rubella titers were available for review, but not mumps titers, we initially assumed that 23 of the 27 (85%) of the exposed Soldiers did not have evidence of immunity to mumps. PUBLIC HEALTH RESPONSE TO IMPORTED MUMPS CASES FORT CAMPBELL, KENTUCKY, 2018

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January June 2018 57 likely received MMR vaccine previously, but simply had no documented evidence of mumps immunity per Army policy as described, we opted to send these 23 Soldiers for mumps IgG serology right away in order to clearly document evidence of mumps immunity. We as than 5 days after exposure would have to be secondary to previously established immunity. Furthermore, if the Soldiers showed evidence of immunity to both measles and rubella, given their young age, it was most likely due to a history of having received at least one dose of tive mumps titers results. In this manner, we were able to establish presumptive immunity for 22 (81%) of the 27 total Soldier contacts. The remaining 5 Soldiers for which presumptive immunity to mumps could not be es tablished were housed in a separate barracks area, and excluded from contact with other Soldiers for postexpo sure days 12 to 25. Follow-up symptom interviews were conducted by Army Public Health Nurses (APHNs) on postexposure days 15, 20, and 26. No symptoms consis Six healthcare workers (HCW) were potentially ex posed to mumps during the care of the index cases. For tunately, the need for isolation and droplet precautions the MEDDAC ED, and this likely limited the number of initially had presumptive evidence of immunity avail able in the electronic health record. This was likely due to the fact that the HCWs were hired prior to 2015 when a more rigorous pre-employment vaccination review was implemented at this facility to achieve more consis tency with guidance in Army Regulation ( AR ) 40-562 10 tion of HCWs. 11 These 3 HCWs were also sent for imme diate mumps IgG serology, and all 3 resulted in positive mumps titers. The HCWs were counseled on the signs and symptoms of mumps, and to stay home should they develop any signs or symptoms suggestive of mumps, but were allowed to continue working after presumptive immunity had been established. The childs school was the source of the majority of resulted in a total of 62 child contacts (age range 3 to 5 tential exposure to a probable mumps case was provided to parents of the other prekindergarten children via a memorandum drafted by FTCKY DPM and a mumps fact sheet sent home with the students on Day 4 of the ceived at least one dose of MMR vaccine, and 47 (76%) had evidence of 2 doses of MMR vaccine available for having no evidence of presumptive immunity to mumps, and were recommended for exclusion from school for postexposure days 12 through 25. When their parents were presented with this recommendation, evidence of at least one prior MMR vaccination was provided to the APHNs for an additional 5 children. This brought the total with at least one prior MMR vaccination to 60 of 62 (97%) children. Two children were excluded from school at the recommendation of FTCKY DPM for post exposure days 12 through 25. Follow-up mumps symp tom interviews were conducted by APHNs on postex posure days 15, 20, and 26. No secondary mumps cases tive evidence of immunity immediately available for partment of Defense Educational Activity (DoDEA), directed that they would be excluded from work and placed on sick leave for postexposure days 12 through 25 unless they were able to provide evidence of pre sumptive immunity to mumps, an additional 7 educa immunity to remain working in the school. Four edu cators (28% of total educator contacts) were excluded from work as they were unable to provide any evidence of presumptive immunity to mumps. As with the other contacts, follow-up mumps symptom interviews were conducted by APHNs on postexposure days 15, 20, and We were fortunate that no secondary cases developed during this contact investigation. Heightened aware ness and surveillance for additional cases continued until 50 days after the initial case presentations (two 25day incubation periods) with no additional cases being CO MM ENT A number of lessons can be learned from this contact investigation for other Army public health profession als to consider in future communicable disease contact investigations on their installation. First, a strong re least at the local and regional level, and as necessary, at the state level) is absolutely key to success. Fort Camp bell has the unique situation of lying astride the state border between Tennessee and Kentucky. This requires working with public health professionals in both states,

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58 http://www.cs.amedd.army.mil/amedd_journal.aspx and maintaining relationships with these professionals through regular contact and interaction. For example, just one month prior to this event, FTCKY DPM had hosted a joint public health emergency preparedness tabletop exercise, which was attended by local public health professionals from several nearby counties in from Fort Campbell DoDEA schools and Fort Campbell Child and Youth Services also attended. The relation ships formed as a result of this event and prior meetings readily available, and that local public health profession als were prepared to react had the contact investigation extended to their jurisdictions. cess helped to ensure that timely and correct information about the investigation was disseminated to the public. and the investigation into a timely press release to local media that was transmitted through social media almost simultaneously with the letters sent by the school to par note, a press release posted on the Fort Campbell MED DAC public Facebook page received over 350 shares and release to a local newspaper was posted on the newspa pers Facebook page and received a similar volume of curate information was provided to the Fort Campbell community in an expedient manner likely helped to pre vent the development of rumors and inaccuracies that Campbell clinical providers and nurses through an email distribution list shortly following the press release. This message provided additional, clinically-relevant in formation about the index cases, and when and where potential exposures would have occurred. It also includ incubation periods and when secondary cases could potentially be seen. 4 This information helped clinicians and nurses to appropriately respond to calls from pa tients and concerned parents who had read the press re lease and were concerned that they had been exposed and/or that they were currently experiencing mumps symptoms. This was particularly important as the pub lic response, via social media and the MEDDAC call the press release, almost a week prior to when secondary cases would have been expected to appear based on in cubation period. The FTCKY DPM leadership also met with MEDDAC department chiefs to review signs and symptoms of mumps, and to ensure that incubation pe riods and exposure locations were understood. noted previously, the Army does not routinely check mumps titers on Soldiers at initial entry training. As such, presumptive immunity could not immediately be established for most Soldiers. However, some practitio ners were unfamiliar with this discrepancy and initially declared presumptive immunity based on an up to date Army Regulation 40562 states Immunity against mumps is not necessary as a military requirement, but may be appropriate in excep tional clinical circumstances such as outbreaks. 10(p15) To this point, the investigation also reiterated that instal lation occupational health clinics should not use MED system of record for maintaining Soldier readiness, and recommendations. Clear documentation of a completed MMR vaccine 2-dose series or positive serology is nec essary for HCWs in accordance with AR 40-562 10(p15) This standard meets and exceeds recommendations for HCW vaccination created by the CDC. In the future, better relationships should be estab lished with local DoDEA leadership. Army Public Health Nurses work frequently with installation Child and Youth Services to ensure a safe and healthy child care environment; however, relationships with DoDEA schools may not be as strong. At Fort Campbell, DoDEA educators did not visit installation occupational health for pre-employment examination, and did not meet with installation occupational health as part of their initial arrival process. As such, Fort Campbell occupational ees, nor did Fort Campbell DoDEA nurses. As on-post educators should be appropriately vaccinated for their work, a better solution may be for these employees to inprocess installation occupational health for an immuni Army Regulation 40-562 10 tion practices with applicability to all DoD uniformed personnel and select civilian employee, as well as the AR 40-562 indicates that as a condition of employment, DoD schoolteachers will ready immune, 10(p12) we found that DoDEA may not rou tinely enforce this requirement within the contiguous PUBLIC HEALTH RESPONSE TO IMPORTED MUMPS CASES FORT CAMPBELL, KENTUCKY, 2018

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January June 2018 59 stallation public health and occupational health assets to curs may allow for greater cooperation in the future and prevent the delay in establishing evidence of presump tive immunity that was noted during this investigation. CONCLUSION Mumps may not be considered a disease of military importance; however, Soldiers may travel of their own accord or be deployed to locations where mumps out cine does not provide 100% immunity against mumps, Soldiers have the potential to develop acute mumps, and may be at greater risk of its complications as adults. Mil itary public health professionals should prepare them selves to respond to mumps cases to prevent the spread of disease, and should be sure to include colleagues in local civilian public health in their planning. This in vestigation clearly illustrates that the magnitude of a contact investigation can quickly increase, particularly when Soldiers are living in close quarters, and when consolidated child care settings are involved. Thus, con tinuous preparation for the possibility of these events through public health emergency response exercises is essential so that even if additional cases appear and in vestigations expand, military public health professionals depend on previously developed collegial relationships to assist in resolving the problem. ACKNOWLEDGE M ENTS Health Nurses MAJ Simone Edwards, CPT Courtney Buchwald, and Ms Jennifer Williams who were essential in conducting and completing this investigation. REFERENCES 1. Rubin SA, Carbone KM. Mumps. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Harrisons Principles of Internal Medicine 19th ed. New York: McGraw Hill Educa tion; 2015: chap 231e. 2. DEpiro J. MumpsIts Back!. Clinician Rev 2015;25(4):24-31. 3. Fiebelkorn AP, Barskey A, Hichman C, Bellini W. Chapter 9: Mumps. In: Roush SW, Baldy LM, Hall MAK, eds. Manual for the Surveillance of Vac cine-Preventable Diseases 6th ed. Atlanta, GA: Centers for Disease Control and Prevention; 2013. Available at: https://www.cdc.gov/vaccines/pubs/ surv-manual/chpt09-mumps.html. Accessed July 24, 2018. 4. Kansas Department of Health and Environment. Mumps Investigation Guideline [internet]. 2018. Available at: http://www.kdheks.gov/epi/Investiga tion_Guidelines/Mumps_Disease_Investigation_ Guideline.pdf. Accessed July 24, 2018. 5. Marin M, Marlow M, Moore KL, Patel M. Recom mendation of the Advisory Committee on Immuni Virus-Containing Vaccine in Persons at Increased MMWR Morb Mortal Wkly Rep 2018;67(1):33-38. 6. Fiebelkorn AP, Lawler J, Curns AT, Brandeburg C, Wallace GS. Mumps postexposure prophylaxis with a third dose of measles-mumps-rubella vac Emerg In fect Dis 2013;19(9):1411-1417. 7. Centers for Disease Control and Prevention. Il lustration of Parotid Gland and Instructions for Collection of Buccal Fluid [internet]. 2010. Avail able at: https://www.cdc.gov/mumps/lab/detectionmumps.html. Accessed June 29, 2018. 8. Department of the Army. ALARACT 255/2014 Implementation of Measles, Mumps, and Rubella (MMR), Polio, and Varicella Vaccine Requirement 2014. 9. Department of the Army. ALARACT 081/2006 The Accession Screening and Immunization Program (ASIP) 2006. 10. Army Regulation 40-562, Immunizations and Che moprophylaxis for the Prevention of Infectious Diseases 11. Centers for Disease Control and Prevention. Im dations of the Advisory Committee on Immuni MMWR Recomm Rep 2011;60(RR-7):1-45. AUTHOR LTC Downs is with the Department of Preventive Campbell, Kentucky.

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60 http://www.cs.amedd.army.mil/amedd_journal.aspx DEVELOPING MEDICAL SURVEILLANCE FOR NEW OCCUPATIONAL HAZARDS When new substances are introduced to the workplace, the potential health risks to exposed workers must be known. If a gap in knowledge exists, an investigation cannot be fully managed using engineering, administra tive, and/or personal protective controls, a medical sur veillance program must be developed and implemented. This publication will focus on the medical surveillance aspect of an overall occupational surveillance program when new substances are introduced to the workplace. To begin developing a medical surveillance program, ough literature search for studies and information relat ed to the substance in question. Toxicologic data, safety data sheets, clinical outcome studies, research and de velopment data, peer-reviewed journal studies or arti cles, and even popular medicine articles are good places to start gathering information. Included in this step is soliciting help from experts with knowledge of the sub stance, obtaining information on how the substance will be used (eg, manufacturing and handling), and gather ing knowledge of how humans have the potential for de veloping morbidity related to the substance in question. This step helps to identify what is known and what is not ogy studies that enlighten occupational health providers The second step is to solicit assistance from the toxi on the new substance that help to determine potential studies should be in areas where there is little knowl edge that address the most likely route(s) of exposure, medical surveillance program that uses this information will be able to successfully monitor the health of po tentially exposed workers, especially if it employs bio marker testing as part of the exam protocol. Examples of Army resources that may be helpful at this step include torate, the Army Research Laboratory, and Edgewood Chemical Biological Center. The third step is to consult with industrial hygiene (IH) and safety personnel at the installation to determine the type of controls that are needed to protect workers who may be exposed to the new substance. If engineering and/or administrative controls are not enough to protect workers from exposure, a recommendation for personal protective equipment (PPE) should be given by IH and implemented by the employer. An exposure monitoring plan should also be developed among industrial hygiene, safety, and medical personnel to address the needs for quantitative data to assess actual worker exposure, vali date the selection and use of appropriate PPE (eg, res pirators), and compare toxicological information with medical observations and expectations. Developing Medical Surveillance Examination Guidance for New Occupational Hazards: The IMX101 Experience W. Scott Monks, MPAS, PA-C ABSTRACT to workers they evaluate. The responsibility for developing a medical surveillance exam, as part of a compre hensive workplace surveillance program, may become the responsibility of the provider working in a clinic on a military installation where manufacturing, testing, and/or use of the material is being conducted. Insensitive within the last few years. This article describes the course of action taken by the occupational health clinics, stitute of Public Health to address the situation of developing a medical surveillance examination during a time when little to no information existed about the components of this new explosive compound.

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January June 2018 61 limited to: American Conference of Governmental In dustrial Hygienists (ACGIH) Threshold Limit Values, cupational Safety and Health Recommended Exposure Limits. Many chemical substance exposure values are published but many have yet to be developed. Army oc cupational health professionals typically follow the most If IH or safety personnel have initially determined that engineering controls are not enough to reduce the ex posure (thus requiring that workers wear PPE), it is rec ommended that they, along with the employer, work to improve existing engineering controls or to develop a new type of engineering control to reduce or eliminate exposure. The ultimate goal is the reduction or elimina tion of PPE, if feasible. termined that medical surveillance is still required, the last step is to attempt to develop a biological exposure index (BEI) for the substance in question. The reference for this process can be found on the ACGIH website (www.acgih.org). A BEI helps to focus the medical sur veillance program towards the health issues that would most concern an occupational health provider. These bi ologic tests need to have as high a level of sensitivity and program should be established for workers who have a potential exposure, including those over the exposure limit regardless of PPE use, maintenance workers who may have short duration but very high exposures, and as PPE control practices. All of these steps should provide enough information for the medical authority to develop a medical surveillance exam that includes the following: appropriate questions for the subjective portion of the exam, appropriate physical exam focus and lab/diagnos tic testing strategy for the objective portion of the exam, and assessment and plan parameters that include fre quency of evaluation (eg, annual, biannual, every 5 years), what to do when abnormal results are found, and criteria for limited duty, medical removal, etc. CASE STUDY: THE EVOLUTION OF THE I MX-101 MEDICAL SURVEILLANCE EX A M INATION Insensitive munitions are munitions which reliably ful inadvertent initiation and severity of subsequent collat eral damage to weapon platforms, logistic systems, and personnel when subjected to unplanned stimuli. 1 The Department of Defense (DoD) recently launched an ini (BAE Systems, Inc, Arlington, VA) is one formulation systems, including the M795 155 mm artillery projectile. 2 guanidine (NQ). Army ammunition plants began pro and work environment surveillance at these plants the same year. At that time, there were limited toxicological studies using animal and in vitro models that described but did not fully explain all possible human health out comes. Because this was a novel compound, previous medical surveillance data was nonexistent. What was known, however, was that certain components were chemically very similar to other explosive compounds (for instance DNAN and 2,4,6-trinitrotoluene (TNT)). It was reasonably assumed that similar compounds would view). When deciding how to proceed with performing medical surveillance examinations, the occupational placed in a unique situation. THE FIRST MEDICAL SURVEILLANCE EX A M INATION GUIDELINES FOR I MX-101 101 components were voiced by Army ammunition plant workers and occupational health personnel at the same rounds. Although toxicity clearances on all substances had been performed as a part of this process, medical surveillance examinations (MSE) of workers and indus the acquisitions process. implemented at active ammunition plants in 2011, there were few studies or toxicologic data (other than the

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62 http://www.cs.amedd.army.mil/amedd_journal.aspx toxicity clearance data) that answered questions about The approach in this early stage was to monitor multiple organ systems that were suspected to be targets of this new compound. The Joint Munitions Command asked conduct additional studies and toxicologic assessments guidelines appeared to exceed what was clinically nec 3 REVIEW OF EARLY MEDICAL SURVEILLANCE DATA workers for analysis in June 2014. The surveillance time period evaluated was from April 2013 through Decem ber 2013. Baseline surveillance exams were completed follow-up exam was completed in September 2013. Two timeframe. ing occupational medicine physicians, physician assis MSE data. The group was looking for any evidence that the original MSE protocol was able to detect an occu pationally-acquired adverse health outcome. Parameters including the workers exposure length and magnitude based on industrial hygiene workplace surveillance data multifaceted nature. determined that the primary focus should be on develop ing and implementing engineering controls that control hygiene workplace surveillance data during this time 8-hr TWA 1.6 mg/m3). There were no exam, lab, or di agnostic test data collected during this time period, sug of primary concern related to the known or suspected tologic/hepatic/metabolic for DNAN, male (rodent) re (Tyvek or cotton ammunition plant coveralls with anti static treatment, nitrile gloves, full-face respirators with tistatic, grounding footwear) appeared to be protecting studies to determine long-term, occupationally propor tocol that was originally implemented likely exceeded what was clinically important to monitor workers ap propriately and that the guidelines should be updated. improved engineering controls to manage potential ex erations include local exhaust (eg, point source) and canopy hood ventilation systems. Work continues today on developing monitoring meth pounds. As the occupational health community devel ops their understanding regarding the routes of entry into a workers body, the techniques that industrial hy situation. Currently, air sampling is done at the plants to evaluate the potential for inhalation exposure. Wipe sampling has been conducted to evaluate skin exposure currently employed may be available in the future. rently used at most plants includes vapor and liquid impervious/barrier-type coveralls, full-face respirator gloves. Some plants still use cotton coveralls and gloves who are using any form of PPE. Although we are lacking studies that can produce BEIs DEVELOPING MEDICAL SURVEILLANCE EXAMINATION GUIDANCE FOR NEW OCCUPATIONAL HAZARDS: THE IMX101 EXPERIENCE

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January June 2018 63 with similar compounds (eg, TNT) that can be used to monitor the health of workers until further research is conducted. UPDATED I MX-101 TO X ICOLOGY DATA The most up-to-date resource for the toxicologic assess 4 The report According to the report, DNAN is the main component that of TNT; the primary target for both is the hemato poietic system. The secondary targets of DNAN include the hepatic system as well as disruption to the metabolic process caused by the metabolite dinitrophenol (DNP). 4 adverse health consequences to humans are not expected 4 However, one study using mice did associate NQ with garding aquatic breakdown products of NQ, and further study is recommended. 4 exposure studies (14-day, repeated oral dose), the mix ture displayed the characteristics of the individual com observed were likely due to the DNAN component of the concentrations similar to those of DNAN alone. 4(p29) count in rat studies). However, due to the presence of mal penetration study showed an increased dermal ab and NQ alone. This suggests potential enhanced toxic ity, possibly due to synergistic, toxicokinetic mixture have not been studied to date. 4 PROPOSED REVISIONS TO THE FIRST MEDICAL SURVEILLANCE GUIDELINES As noted earlier, the medical surveillance approach orig what would generally be considered as an appropriate balance between cumulative sensitivity and cumula exposure. Like false negatives, false positives may be harmful to individuals so an artful balance and minimi Based on the new toxicology knowledge described above and in response to calls from stakeholders to 3 on exposed workers, the new guidelines attempt to rec oncile laboratory and diagnostic tests that have no ap plicable biological monitoring capability with ones that have evidence-based studies to support their use. The revised surveillance guideline focuses on the po posed revisions to these guidelines are shown in the Table. EX PLAINING THE CHANGES TO I MX-101 MEDICAL SURVEILLANCE As mentioned earlier, DNAN and TNT have similar ef 3 suggest use of an approach similar to TNT surveillance by monitoring a complete blood count (CBC) primarily focusing on red blood cells (RBCs), glucose-6-phosphate dehydroge advised in Technical Bulletin (Medical) 297. 5 Due to the panel was advised. Finally, NQ displayed the potential fore, a dipstick urinalysis was recommended. Frequency of testing was another consideration when designing the surveillance guidelines. Hematologic

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64 http://www.cs.amedd.army.mil/amedd_journal.aspx metrics require the most frequent evaluation. The origi nal guidelines recommended monthly blood tests. When evaluating CBC results, however, it would be unlikely to see rapid changes in the RBCs (especially the hemoglo sure. A 90-day follow-up after the baseline examination is more in line with the normal RBC lifecycle and early LFTs related to chemical exposure, or subclinical signs of health changes before a worker becomes symptomatic. If a worker presents symptomatically sooner than 90 days in the initial 90 days of employment and/or exposure to it were the 90-day evaluation. Subsequently, semiannual exams should be conducted to include the 90-day exam elements with the addition of regular haptoglobin (Hp) dehydrogenase (LDH) or peripheral blood smear evalua tion further strengthens the surveillance regimen of tests to monitor any potential hematological changes with as currence, for hemolytic anemia as possible. The purpose and Hp levels below the laboratory reference range dur ing the semiannual exam is to detect an exposed worker with the potential for hemolytic anemia. The addition of for hemolysis (a normal value for both of these tests has a 92% sensitivity for ruling out hemolysis). 6,7 If hemolysis CBC, an increase in the RC, and abnormalities on the peripheral blood smear (eg, schistocytes, bite cells, spur cells), the anemia is likely of the hemolytic type. The the occupational health providers clinical acumen, are cause of the described exam abnormalities. In the case of the postaccident exam should follow the elements of a semiannual exam, with follow-up examinations as de termined by the occupational medicine provider (likely every 90 days for 2 or more consecutive cycles). Proposed Revisions to IMX101 Medical Surveillance Laboratory and Diagnostic Testing Guidelines Baseline Examination History and physical (with modified questionnaires) CBC with manual differential Comprehensive metabolic panel (including AST, ALT, and ALP) Dipstick urinalysis Gamma-glutamyltransferase (GGT) Glucose-6-phosphate dehydrogenase (G6PD) 90-day Examination Same as Baseline exam but WITHOUT G6PD Semiannual Examination Same as 90-day exam with the addition of: Haptoglobin (Hp) Reticulocyte count (RC) Optional Tests Lactate dehydrogenase (LDH) Peripheral blood smear Other tests at providers discretion as needed Termination Examination Same as Semiannual exam Additional Surveillance Examination Elements Pulmonary function test (spirometry) Original IMX101 Medical Surveillance Laboratory and Diagnostic Testing Guidelines (used during April-December 2013 data review) ALL Examinations CBC with manual differential Comprehensive metabolic panel Lipid panel Thyroid panelthyroid stimulating hormone (TSH), free T4, T3 Thyroid peroxidase antibody (TPO antibody) Thyroglobulin antibody (TG antibody) Follicle stimulating hormone (FSH) Luteinizing hormone (LH) Testosterone (total and free) Prolactin Sex hormone binding globulin (SHBG) Mensperm count (offered but none collected) WomenIf of childbearing age (if desired): estradiol, 3-day anti-Mullerian hormone (AMH) Baseline Examination ONLY History and physical Aspartate aminotransferase (AST) Alanine aminotransferase (ALT) Alkaline phosphatase (ALP) Electrocardiogram (EKG) Chest X-ray Low testosterone questionnaire (men) Obstetrics / gynecological history (women) Thyroid questionnaire Additional Surveillance Examination Elements Pulmonary function test (spirometry; baseline results only) Comparison of the IMX101 Medical Surveillance Guidelines. 3 DEVELOPING MEDICAL SURVEILLANCE EXAMINATION GUIDANCE FOR NEW OCCUPATIONAL HAZARDS: THE IMX101 EXPERIENCE

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January June 2018 65 to a recent CDC study discussing infertility rates among men aged from 15 to 44 years have sought medical help to have a baby (conceive or prevent miscarriage). 8 Test ing for changes in both male and female sexual hormones male workers as part of the original surveillance proto related infertility when compared to the background 101 compounds and to monitor the unlikely but still pos 3 developed a model questionnaire that could be used to evaluate workers reproductive health. The potential for a rapidly changing plant operations ance is an issue that poses a challenge. For example, a worker (or segment of workers) in a plant may produce cult from the occupational health perspective. This issue While it is true that the above testing regime has the it is believed that this method is more focused on the scheme to detect these issues with fair certainty. The absence of BEIs. If the evaluation focuses on the known non-evidence-based testing, then the surveillance is achieving its goal until a better method is developed. fort that was placed into producing a clearly written health risk management message explaining why the medical surveillance. It is essential to explain to occupa tional health clinic providers and workers why their test ing regimen would be changing in a way that they can understand and accept the reasoning behind the decision. SU MM ARY retroactively trying to develop a medical surveillance program to address potential exposure to new com pounds. Attempting to accomplish all of the necessary steps as discussed in this article to build an evidencebased approach for medical surveillance is made more challenging after production has started and workers are potentially exposed. This approach has potential health risk implications for the workers involved. It appears vidual compounds have occurred to date. It is possible that we are currently monitoring workers with the most 101, but lack the studies to prove that this is the case. workers than we were a few years ago. There are still knowledge gaps that must be explored before it can be said that there is a best-case scenario. That scenario includes industrial hygiene monitoring that is techni els, engineering controls that reduce exposures as much possible, the use of PPE (as appropriate) based on the remaining exposure risk, and an evidence-based medi cal surveillance program that evaluates and detects the ity. The Army and all stakeholders remain dedicated to improving their portion of this program and ultimately will focus on what is best to protect the worker. ACKNOWLEDGE M ENTS the Toxicology Directorate at the APHC, Ms Lindsey Pete Matos for their contributions to this article. REFERENCES 1. Paper presented at: National Defense Industrial As sociation Insensitive Munitions & Energetic Mate rials Technology Symposium; 2007; Miami, FL. 2. Industrial Association Insensitive Munitions & Energetic Material Technology Symposium; 2012; Las Vegas, NV. 3. Medical Surveillance Ex amination for Workers Exposed to IMX-101 and Its Components [white paper]. Aberdeen Proving 2014.

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66 http://www.cs.amedd.army.mil/amedd_journal.aspx 4. Williams L, Johnson M, Eck WS. Toxicology Re port No. S.0024589-15. Toxicology Assessment of IMX-101-Update Aberdeen Proving Ground, MD: 2014. 5. Department of the Army. Technical Bulletin Medi cal 297. Guidelines for Exposure Prevention, Med ical Surveillance and Evaluation of Workers with the Potential for Exposure to 2,4,6-Trinitrotoluene (TNT). Army; 2010. 6. Marchand A, Galen RS, Van Lente F. The predic tive value of serum haptoglobin in hemolytic dis ease. JAMA 1980;243(19):1909-1911. 7. Galen RS. Application of the predictive value mod Clin Lab Med 1982;2(4):685-699. 8. Chandra A, Copen CE, Stephen EH. Infertility Ser tional Survey of Family Growth, 1982-2010. Natl Health Stat Report 2014;22(73):1-21. AUTHOR Proving Ground, Maryland. DEVELOPING MEDICAL SURVEILLANCE EXAMINATION GUIDANCE FOR NEW OCCUPATIONAL HAZARDS: THE IMX101 EXPERIENCE

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January June 2018 67 BACKGROUND Globally, approximately 2 million new incident cancer cases are caused by infectious diseases every year, and 600,000 of these cases are caused by the Human Papil lomavirus (HPV). 1 Interestingly, HPV is also the most common sexually transmitted infection (STI) in the tal HPV infections yearly, half of which are diagnosed among individuals 15 to 24 years of age. 2 From 2003 to 2006, HPV prevalence was as high as 42.5% among fe males aged 14 to 59 years, 3 the majority of whom (53.8%) were aged 20 to 24 years. 4 Further, studies have demon strated that HPV seroprevalence is actually low (1% to 8%) in late adolescence but increases with age, reaching up to 15% to 35% by age 40 years. 5 However, HPV ac quisition may be accelerated in highly sexually active populations, such as military personnel. 6,7 For example, HPV seroprevalence was reported to be as high as 45% to 51% among active duty (AD) women. 7 Another study found that incident infections of HPV were common with more than one-third of male AD service members seroconverting to one or more of the HPV serotypes. 5 In military, 8 although HPV vaccination coverage remains consistently low. 9 During the years 2000 to 2012, there were an estimated 304,021 incident cases of HPV (17.5 per 100,000 person-years) among AD service mem bers. 10 To put these data in perspective, the number of healthcare visits due to HPV alone was greater than gonorrhea and chlamydia combined. 5 More recently, a study among female AD service members revealed only 22.5% vaccination uptake of one dose or more. 9 Although most HPV infections are self-limited and asymptomatic, 11 persistent infection with high-risk HPV types can cause cancers of the cervix, vagina, vulva, penis, anus, rectum, and oropharynx. 12-14 HPV 16 and HPV 18 are high-risk types that are more likely to persist and progress to cancer. 15,16 Whereas, low-risk HPV types 6 and 11 typically cause anogenital warts and respiratory papillomatosis. 17 Thus, cancer pre vention and treatment requires public health interven tions and early detection. have been one of the greatest success stories in pub lic health. The Food and Drug Administration has ap proved 2 cancer preventive vaccines, one for Hepatitis B virus 18 that is a leading cause of liver cancer, the other for HPV. In 2006, a 3-dose HPV quadrivalent vaccine (4vHPV) (Gardasil; Merck & Co, Inc, Whitehouse Sta against several HPV strains (types 6, 11, 16, 18) that are responsible for about 70% of cervical cancers and 80% of genital warts. 9 The Advisory Committee on Immuni Control and Prevention (CDC) recommended its use in females aged 11-12 years, and catch-up vaccination for females aged 13 to 26 years who have not been previous ly vaccinated. 19 A bivalent HPV vaccine (2vHPV) (Cer was licensed in 2009. 20 The ACIP also expanded their recommendation in 2009 to include vaccination with the 4vHPV for males between ages 9 and 26 years. 21 In 2014, a 9-valent HPV vaccine (9vHPV) (Gardasil 9; Merck & Co, Inc) became available. 22 The ACIP recom mended that any of these 3 vaccines be used for routine vaccinations of females, while only 2 vaccines (4vHPV and 9vHPV) were indicated for males. 23 In 2016, ACIP updated their recommendations regarding dosing sched ules and administration of the 9vHPV vaccine. 24,25 The notable change from prior ACIP reports 22,23 was the re duction to a 2-dose schedule for males and females who Missed Opportunities in Human Papillomavirus Vaccination Uptake Among US Air Force Recruits, 2009-2015 Jenny Lay, MPH David Hrncir, MD, MPH Lynn Levin, PhD, MPH The material contained in this study was reviewed by the Walter Reed Army Institute of Research. There is no objection to its presentation and/or publication. The investigators have adhered to the policies for protection of human subjects as prescribed in Army Regulation 7025 : Use of Volunteers as Subjects of Research, 1990

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68 http://www.cs.amedd.army.mil/amedd_journal.aspx start the series at ages 9 to 14 years. For young adults between the ages of 15 to 26 years, the dosing schedule remained unchanged at 3 doses. 24,25 The 5 additional types included in 9vHPV vaccine con tained oncogenic types 31, 33, 45, 52, and 58 which added primary protection against cervical cancer and cervical pre-cancers, including cervical intraepithelial neoplasia grade 2 or 3 and adenocarcinoma in situ. 23,26 In late 2016, when the 9vHPV vaccine was widely dis 24 the CDC estimated an average of 30,700 HPV-related cancers diagnosed yearly, of which approximately 92% were attributed to these 15,27 Among females, this translates to prevention of approximately 81% of cervical, 73% of vaginal, and 63% of vulvar cancers. 15 Among males, 57% of penile cancer could be prevented. Among males and females combined, an estimated 88% of anal and 66% of oropharyngeal cancers would be preventable. 15 prevented per year with full vaccine coverage with the 27,28 Addi tionally, close to 90% of all anogenital warts would be prevented along with most cases of recurrent respira tory papillomatosis. 17 Even though these vaccines are available, one study revealed an increased incidence of HPV-associated cancers occurring in 11.7 per 100,000 population from 2008 to 2012, compared with the rate of 10.8 per 100,000 population from 2004 to 2009. 27,29 Although HPV vaccination uptake has increased in both females and males since a licensed HPV vaccine was 22 low coverage among adolescent populations continues to exist. 30 During the period 2014-2015, the 1 dose or more coverage was only 62.8% for females and 49.8% for males among the age group 13 to 17 years. Comparatively, the 1 dose or more coverage (56.1%) for females and males combined was less than the coverage for the 1 dose or more (81.3%) of meningococcal 4-valent conjugate vaccine and the coverage for the 1 dose or more (86.4%) of tetanusdiphtheria-acellular pertussis vaccine. This disparity underscores the extent of the HPV vaccination uptake 30 Thus, catch-up vaccination recommendations herald an op portunity for increased awareness and public health ef Several factors support the ACIP recommendation to vaccinate males and females in the catch-up age range. These include studies showing high HPV vaccine ef with prior HPV exposure, 31 reports on the prevalence 3 lack of exposure to high-risk HPV types included in the 9vHPV vaccine, 32 within this older population. 33,34 Less is known, however, about HPV vaccine uptake in the catch-up group of old er teens and young adults as the National Health Inter view Survey only began collecting data in 2013 on age 26 years. 35 In one study, HPV vaccination uptake among adults aged 19 to 26 years who reported ever receiv ing one dose or more of an HPV vaccine was quite low. Among women aged 19 to 26 years, approximately 12% as catch-up sometime between ages 19 to 26 years, com pared to only 2% of men within similar age groups. 36 Following the ACIP recommendations, 22 the Department of Defense (DoD) made the 9vHPV vaccine available to service members aged 17 to 26 years. 37,38 In 2013, the Presidents Cancer Panel developed a strategy to acceler ate vaccine coverage. 1 DoD created a set of instructions 39 in order to promote and Human Services Healthy People 2020 goals were updated to reach higher HPV vaccination coverage in 40 More recently, the National Cancer Institute issued a joint statement to focus on the low cov erage rates of HPV vaccinations and the missed opportu nities to prevent vaccine preventable cancer. Placing HPV Cancer Program has focused on a vaccination campaign against avoidable cancers. The campaign addresses one ventable cancer: reduce missed clinical opportunities to recommend and administer HPV vaccines 41 sist for both the adolescent and catch-up age groups of older teens and young adults. The main goal of this study HPV vaccine uptake rates among AD Air Force (AF) recruits (some of whom have prior doses of HPV vac cination documented in their historical electronic DoD 2015) in order to highlight the importance of continued mine HPV vaccine uptake by HPV vaccine dose and to quantify missed opportunities for HPV vaccination dur ing basic training among this population in the catch-up age group, aged 17 to 26 years. MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE AMONG US AIR FORCE RECRUITS, 2009-2015

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January June 2018 69 METHODS A retrospective descriptive analysis of electronic re cords was performed to determine vaccine uptake and the percent of missed opportunities for HPV vaccina tion among AD AF recruits. The study population was tary Training System and included all AD AF recruits attending basic training at Joint Base San AntonioVaccination codes and other medical encounter data were obtained from the Aeromedical Services Informa tion Management System (ASIMS) and the Air Force and military service data, including birth year, age, sex, status prior to the beginning of basic training, were ob tained from the Defense Enrollment Eligibility Report Recruits who were younger than 17 years, older than 26 years, or did not complete basic train ing were excluded from the analysis. HPV vaccination uptake among re cruits for the period prior to entry into military service and during basic training was calculated using ASIMS data. Vaccine uptake rates were de termined according to sex, age group, birth year, race/ethnicity, marital sta tus, year of entry into basic military HPV doses. Any recruit with a record of receiving 3 or more HPV doses was considered to have completed the dose series. A missed opportunity for HPV vacci patient encounter (non-HPV infection related) occurring on or after initial intake within a recruits basic training dates when he or she was eligible for HPV vaccination and the vaccine was not administered. The number and percentage of missed opportunities to initiate HPV vaccination during basic training by demographic and service-related characteristics were data for recruits who never received one dose of HPV vaccine prior to entry or during basic training. Sta tistical methods included computing means and proportions to describe vaccine uptake rates and missed opportunities in the study population. Data Inc, Carey, NC). Approval to conduct the study was ob tained from the Institutional Review Boards of Walter Reed Army Institute of Research and Joint Base San Antonio-Lackland. RESULTS The study population included a total of 198,888 AD AF recruits aged 17 to 26 years who had completed basic 2015. The mean age of the recruits was 20.16 years (SD 2.16 years), with the majority comprised of males (79%), non-Hispanic whites (67%), and single marital status (69%) (Table 1). Among all recruits in this predominately male population, 0.44% received one HPV dose, 0.30% received 2 doses, and 0.83% had 3 or more doses (Table 2). Female recruits had much higher vaccine coverage than males (one or more dose(s) was 5.7% for women and 0.47% for men). Coverage for one or more HPV dose(s) was highest in the youngest catch-up age group 17-20 (1.7%) and then de creased somewhat with increasing age (Table 2). A pattern of increasing vac cine uptake with each subsequent birth cohort also was observed. Among race/ethnic groupings, non-Hispanic whites (1.2%) had the lowest vaccine uptake at each vaccine dose (Table 2). Single recruits also had slightly lower vaccine uptake for one or more HPV dose(s) (1.5%) compared with mar ried recruits (1.8%) (Table 2). In ad dition, vaccine uptake among recruits increased with each year of entry into basic training during the study period, 2009-2015 (Table 2). Among the subset of 22,720 recruits status, patterns of vaccine uptake by demographic and service-related characteristics were similar to those found for all recruits; however, HPV coverage was much higher compared with recruits without prior TRICARE uptake for one or more HPV dose(s) among women who were prior ben status (Table 3). Table 1 Demographic Characteristics of US Air Force Recruits, 2009-2015 ( N= 198,888 ) Demographic Category n (%N) Sex Male 157,129 (79%) Female 41,759 (21%) Age Group, years 17 20 129,696 (65%) 21 23 49,222 (25%) 24 26 19,970 (10%) Cohort Year 1983 1986 10,786 (5%) 1987 1990 57,171 (29%) 1991 1994 102,038 (51%) 1995 1998 28,863 (15%) Race/Ethnicity White, non-Hispanic 133,015 (67%) Black, non-Hispanic 31,135 (16%) Hispanic 19,372 (10%) Asian/Pacific Islander 7,770 (4%) Other 7,596 (4%) Marital Status Married 59,867 (30%) Single 137,789 (69%) Other 1,223 (1%) Year of Entry 2009 10,504 (5%) 2010 33,486 (17%) 2011 35,100 (18%) 2012 35,272 (18%) 2013 31,627 (16%) 2014 29,692 (15%) 2015 23,207 (12%) Cohort year not determined for 6 recruits.

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70 http://www.cs.amedd.army.mil/amedd_journal.aspx Table 4 presents the results of missed opportu AD AF recruits for whom the data showed that they were never vaccinated against HPV. the HPV vaccination, 99.9% had one or more missed opportunities, 95.3% had 2 or more missed opportunities, and 76% had 3 or more dose. CO MM ENT In this study, we determined HPV vaccine up take and missed opportunities to initiate the HPV vaccination series among a population of AD AF recruits between the ages of 17 to 26 years, a catch-up age group for routine HPV vaccination recommended by the ACIP among those who have not been previously vacci nated. Male recruits comprised 79% of this study population. The particularly low vaccine uptake of 5.7% for women with one or more dose(s) and 0.47% for men with one or more dose(s) was likely due to the inadequate cap ture of nonmandated HPV vaccine information in a recruits ASIMS record. In addition, the observed low coverage among males may be the result of ACIP recommendations for HPV vaccination for males in the catch-up age range during the study period. 21-23 As of 2016, ACIP recommends routine HPV vaccination among males up to age 21 if they were not previously vaccinated or had not completed the 3-dose se ries. However, ACIP states that the HPV vac 23 uptake in military populations have conducted female only studies. In a relatively large study of 270, 257 age-eligible service women in the Army, Air Force, Navy, Marine Corps, and Coast Guard, 22.5% received at least one HPV dose during the study period, 2006-2011. 9 In a smaller study conducted at an Army medical center, 14.8% of eligible AD service women aged 18 to 26 years received one or more HPV vaccine doses during the period 2007-2010, 42 while another study conducted at a Navy medi ries had higher vaccination coverage than AD service women. 43 While we also found higher vaccine uptake tronic records were available, the vaccine coverage was only 25.2% for women and 3.8% for men, an alarmingly low uptake among a population that has full access to healthcare. There were numerous well-care medical encounters during basic training among this population of AD AF MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE AMONG US AIR FORCE RECRUITS, 2009-2015 Table 2 HPV Vaccination Uptake Among US Air Force Recruits, 2009-2015. Demographic Category Number in Category n Number of HPV Vaccinations 1 Dose n 1 (% n ) 2 Doses n 2 (% n ) 3 Doses n 3 (% n ) Study Population Total 198,888 881 (0.4%) 605 (0.3%) 1,658 (0.8%) Sex Male 157,129 315 (0.2%) 176 (0.1%) 253 (0.1%) Female 41,759 566 (1.4%) 429 (1.0%) 1,405 (3.4%) Age Group, years 17 20 129,696 598 (0.5%) 421 (0.3%) 1,143 (0.9%) 21 23 49,222 208 (0.4%) 135 (0.3%) 373 (0.8%) 24 26 19,970 75 (0.4%) 49 (0.2%) 142 (0.7%) Cohort Year 1983 642 5 (0.8%) 1 (0.2%) 2 (0.3%) 1984 1,715 6 (0.3%) 1 (0.1%) 6 (0.3%) 1985 3,314 11 (0.3%) 8 (0.2%) 11 (0.3%) 1986 5,115 14 (0.3%) 11 (0.2%) 34 (0.7%) 1987 7,848 28 (0.4%) 9 (0.1%) 34 (0.4%) 1988 11,126 42 (0.4%) 26 (0.2%) 72 (0.6%) 1989 15,785 62 (0.4%) 37 (0.2%) 92 (0.6%) 1990 22,412 79 (0.4%) 57 (0.3%) 155 (0.7%) 1991 27,876 102 (0.4%) 78 (0.3%) 207 (0.7%) 1992 27,524 99 (0.4%) 71 (0.3%) 184 (0.7%) 1993 25,120 129 (0.5%) 79 (0.3%) 230 (0.9%) 1994 21,518 133 (0.6%) 92 (0.4%) 262 (1.2%) 1995 16,300 83 (0.5%) 63 (0.4%) 210 (1.3%) 1996 9,843 66 (0.7%) 51 (0.5%) 120 (1.2%) 1997 2,710 21 (0.8%) 21 (0.8%) 39 (1.4%) 1998 10 1 (10%) 0 (0%) 0 (0%) Race/Ethnicity White, non-Hispanic 133,015 403 (0.3%) 301 (0.2%) 946 (0.7%) Black, non-Hispanic 31,135 221 (0.7%) 115 (0.4%) 243 (0.8%) Hispanic 19,372 101 (0.5%) 87 (0.4%) 208 (1.1%) Asian/Pacific Islander 7,770 71 (0.9%) 45 (0.6%) 87 (1.1%) Other 7,596 85 (1.1%) 57 (0.8%) 174 (2.3%) Marital Status Married 59,867 275 (0.5%) 217 (0.4%) 572 (1.0%) Single 137,789 584 (0.4%) 381 (0.3%) 1,069 (0.8%) Other 1,223 85 (7.0%) 57 (4.7%) 174 (14.2%) Year of Entry 2009 10,504 51 (0.5%) 23 (0.2%) 60 (0.6%) 2010 33,486 90 (0.3%) 58 (0.2%) 155 (0.5%) 2011 35,100 127 (0.4%) 80 (0.2%) 238 (0.7%) 2012 35,272 151 (0.4%) 86 (0.2%) 280 (0.8%) 2013 31,627 164 (0.5%) 119 (0.4%) 284 (0.9%) 2014 29,692 142 (0.5%) 129 (0.4%) 327 (1.1%) 2015 23,207 156 (0.7%) 110 (0.5%) 314 (1.4%) Cohort year not determined for 6 recruits.

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January June 2018 71 99% of recruits had one or more missed opportunities to initiate the vaccination series. A study of women with private insurance also reported that a large percentage (97.1%) of unvaccinated women in the catch-up age range had at least one missed opportunity to receive the 44 It is important to note that an opportunity for HPV vaccination can be con sidered an opportunity to reduce risk of several HPVassociated cancers including carcinomas of the cervix and squamous cell cancers of the vagina, vulva, penis, anus, rectum, and oropharynx. 13-15 A major strength of the current evidence-based study is the inclusion of all AD AF recruits during the period HPV uptake and trends. This study is also one of few 45 that describes vaccine uptake and missed opportunities among males in the catch-up age range, an age group HPV vaccination campaign. Some limitations, however, should also be considered. Information on prior history of HPV vaccination can be captured in ASIMS among HPV vaccination is not mandatory for AD AF recruits, this information is provided on a voluntary basis for the majority of recruits. Thus, HPV vaccine uptake rates may be grossly underestimated among recruits that no available documentation of HPV vaccination from Table 3 2009-2015. Demographic Category Total n 1 1 Dose % n 1 2 Doses % n 1 3 Doses % n 1 Total n 2 1 Dose % n 2 2 Doses % n 2 3 Doses % n 2 Study Population Total 176,168 0.14% 0.09% 0.32% 22,270 2.79% 1.94% 4.85% Sex Male 140,519 0.03% 0.02% 0.03% 16,610 1.61% 0.92% 1.30% Female 35,649 0.56% 0.40% 1.46% 6,110 6.01% 4.71% 14.50% Age Group, years 17 20 113,942 0.11% 0.10% 0.32% 15,754 2.98% 1.98% 4.96% 21 23 43,719 0.18% 0.09% 0.29% 5,503 2.38% 1.76% 4.51% 24 26 18,507 0.22% 0.10% 0.38% 1,463 2.32% 2.12% 4.92% Cohort Year 1983 1986 10,531 0.28% 0.15% 0.39% 255 2.75% 1.96% 4.71% 1987 1990 51,319 0.18% 0.09% 0.30% 5,852 2.05% 1.42% 3.42% 1991 1994 89,020 0.12% 0.10% 0.33% 13,018 2.72% 1.77% 4.56% 1995 1998 25,275 0.07% 0.06% 0.28% 3,588 4.29% 3.37% 8.28% Race/Ethnicity White, non-Hispanic 119,929 0.10% 0.06% 0.31% 13,086 2.12% 1.72% 4.42%% Black, non-Hispanic 26,898 0.24% 0.14% 0.23% 4,237 3.68% 1.82% 4.30% Hispanic 17,123 0.13% 0.16% 0.38% 2,249 3.47% 2.67% 6.36% Asian/Pacific Islander 6,785 0.28% 0.18% 0.46% 985 5.28% 3.35% 5.69% Other 5,433 0.26% 0.22% 0.57% 2,163 3.28% 2.08% 6.61% Marital Status Married 52,797 0.14% 0.12% 0.40% 7,070 2.87% 2.16% 5.09% Single 122,291 0.13% 0.08% 0.27% 15,498 2.73% 1.84% 4.74% Other 1,072 1.21% 0.47% 0.84% 151 5.96% 1.32% 5.30% Year of Entry 2009 10,477 0.49% 0.22% 0.57% 27 0.00% 0.00% 0.00% 2010 30,137 0.14% 0.08% 0.25% 3,349 1.40% 0.99% 2.36% 2011 30,999 0.14% 0.13% 0.30% 4,101 2.07% 1.00% 3.54% 2012 30,807 0.11% 0.08% 0.34% 4,465 2.60% 1.34% 3.90% 2013 27,605 0.13% 0.08% 0.35% 4,022 3.21% 2.41% 4.67% 2014 25,898 0.07% 0.08% 0.29% 3,794 3.29% 2.87% 6.64% 2015 20,245 0.11% 0.05% 0.25% 2,962 4.49% 3.38% 8.91% Cohort year not determined for 6 recruits.

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72 http://www.cs.amedd.army.mil/amedd_journal.aspx electronic medical records. Also, this study population is comprised primarily of men in the catch-up age group for which HPV vaccination may not be readily avail able in the outpatient setting. In addition, validation of information on the timing to receive a second or third dose of the vaccine series during basic training could not be determined for vaccine-eligible recruits. It was only possible, therefore, to estimate missed opportuni ties among recruits who never received the vaccine, but information was not available to determine missed op portunities for the second or third dose. Moreover, some recorded missed opportunities may have resulted from administrative medical encounters rather than encoun ters for preventive care. Finally, the study population was comprised of AD AF recruits only, so the results may not be gen forces. CONCLUSION tion among this at-risk population of AD AF military recruits, repre senting the catch-up age group, will help reduce missed opportunities for HPV vaccination. In turn, this will ultimately lead to the reduc tion in several cancers that are caus should be made to address barri ers to administer HPV vaccines in medical care encounters dur ing basic training as this is a read ily accessible population. 46 Public creased HPV vaccination uptake and decreased missed opportunities among the AD recruit population are feasible and necessary. Coordi within the AF as well as in the other services are needed to improve HPV include increased initiation of the recommended doses for age-eligible policies to provide access to vac cination for all age-eligible recruits Healthy People 2020 39 and the Presidents Cancer Pan el. 1 Further research in HPV vaccination uptake rates in the catch-up age group among the other branches of the armed forces is warranted. ACKNOWLEDGE M ENTS Joint Base San AntonioLackland for their assistance in preparing the ASIMS dataset for this study. Particularly, Dr Rebecca Hall and Mr David Tucker were instrumental in the collection and coordination of the ASIMS data. We also thank Ms Jan ice Gary of the Walter Reed Army Institute of Research who played a key role in the overall management of this research. MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE AMONG US AIR FORCE RECRUITS, 2009-2015 Table 4 Number of Missed Opportunities for HPV Vaccination Among US Air Force Recruits Who Had Not Been Vaccinated Upon Reporting for Initial Training, 2009-2015. Demographic Category Number of Missed Opportunities Total n 1 1 or More n 2 % n 2 2 or More n 3 % n 3 3 or More n 4 % n 4 Study Population Total 195,744 195,607 99.9% 186,516 95.3% 148,705 76.0% Sex Male 156,385 156,272 99.9% 148,373 94.9% 120,030 76.8% Female 39,359 39,335 99.9% 38,143 96.9% 28,675 72.9% Age Group, years 17 20 127,534 127,434 99.9% 121,964 95.6% 100,019 78.4% 21 23 48,506 48,482 100.0% 45,886 94.6% 34,785 71.7% 24 26 19,704 19,691 99.9% 18,666 94.7% 13,901 70.5% Cohort Year 1983 1986 10,676 10,671 100.0% 10,469 98.1% 8,999 84.3% 1987 1990 56,478 53,448 94.6% 51,443 91.1% 42,579 75.4% 1991 1994 100,372 100,314 99.9% 95,166 94.8% 75,187 74.9% 1995 1998 28,188 28,145 99.8% 26,411 93.7% 21,920 77.8% Race/Ethnicity White, non-Hispanic 131,365 131,268 99.9% 125,795 95.8% 101,227 77.1% Black, non-Hispanic 30,556 30,529 99.9% 29,018 95.0% 22,443 73.4% Hispanic 18,976 18,971 100.0% 17,864 94.1% 14,082 74.2% Asian/Pacific Islander 7,567 7,566 100.0% 7,200 95.1% 5,797 76.6% Other 7,280 7,273 99.9% 6,639 91.2% 5,156 70.8% Marital Status Married 58,803 58,785 100.0% 56,552 96.2% 45,698 77.7% Single 135,755 135,636 99.9% 128,975 95.0% 102,218 75.3% Other 1,186 1,185 99.9% 988 83.3% 788 66.4% Year of Entry 2009 10,370 10,350 99.8% 9,975 96.2% 8,196 79.0% 2010 33,183 33,179 100.0% 32,989 99.4% 27,790 83.7% 2011 34,655 34,645 100.0% 34,369 99.2% 29,803 86.0% 2012 34,755 34,732 99.9% 33,134 95.3% 27,414 78.9% 2013 31,060 31,043 99.9% 28,185 90.7% 18,713 60.2% 2014 29,094 29,072 99.9% 26,769 92.0% 19,711 67.7% 2015 22,627 22,586 99.8% 21,095 93.2% 17,078 75.5% Cohort year not determined for 6 recruits.

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January June 2018 73 REFERENCES 1. Accelerating HPV Vaccine Uptake: Urgency for Ac tion to Prevent Cancer. A Report to the President of the United States from The Presidents Cancer Panel Bethesda, MD: National Cancer Institute; 2014. Available at: https://deainfo.nci.nih.gov/ad visory/pcp/annualreports/HPV/PDF/PCP_Annu al_Report_2012-2013.pdf. Accessed February 23, 2018. 2. Satterwhite CL, Torrone E, Meites E, et al. Sexu men: prevalence and incidence estimates, 2008. Sex Transm Dis 2013;40(3):187-193. 3. of genital human papillomavirus among females in tion Examination Survey, 2003-2006. J Infect Dis 2011;204:566-573. 4. man papillomavirus (HPV) 6, 11, 16, and 18 preva Health and Nutrition Examination Survey, 2003pact? J Infect Dis 2011;204:562-565. 5. Agan BK, Macalino GE, Nsouli-Maktabi H, et al. Human papillomavirus seroprevalence among men entering military service and seroincidence after ten years of service. MSMR 2013;20(2):21-24. 6. Goyal V, Mattocks KM, Sadler AG. High-risk be havior and sexually transmitted infections among J Wo mens Health (Larchmt) 2012;21(11):1155-1169. 7. Shah KV, Daniel RW, Tennant MK, et al. Diagno sis of human papillomavirus infection by dry vagi nal swabs in military women. Sex Transm Infect 2001;77:260-264. 8. vice members before and after the introduction of the quadrivalent human papillomavirus vaccine. MSMR 2013;20:17-20. 9. Maktabi H, Ludwig SL, Eick-Cost A, et al. Quad rivalent human papillomavirus vaccine initia component service women, 2006-2011. MSMR 2012;19:16. 10. Armed Forces Health Surveillance Center. Sexu Armed Forces, 2000-2012. MSMR 2013;20(2):5-10. 11. Trottier H, Franco EL. The epidemiology of geni tal human papillomavirus infection. Vaccine 2006;24(suppl 1):S4-S15. 12. Fahn S, Cohen G. The oxidant stress hypothesis in Parkinsons disease: evidence supporting it. Ann Neurol 1992;32:804-812. 13. Yakar S, Liu JL, Stannard B, et al. Normal growth and development in the absence of hepatic insulinlike growth factor I. Proc Natl Acad Sci U S A 1999;96:7324-7329. 14. Shiels MS, Kreimer AR, Coghill AE, et al. Anal distinct patterns by histology and behavior. Cancer Epidemiol Biomarkers Prev 2015;24:1548-1556. 15. sessment of HPV types in cancers: implications for current and 9-valent HPV vaccines. J Natl Cancer Inst 2015;107(6):djv086. Available at: https://aca demic.oup.com/jnci/article/107/6/djv086/872092. Accessed February 23, 2018. 16. man papillomavirus genotypes and the cumula tive 2-year risk of cervical precancer. J Infect Dis 2006;194:1291-1299. 17. Lacey CJ, Lowndes CM, Shah KV. Chapter 4: Burden and management of non-cancerous HPVrelated conditions: HPV-6/11 disease. Vaccine 2006;24(suppl 3):S3/35-41. 18. Mast EE, Margolis HS, Fiore AE, et al. A compre States: recommendations of the Advisory Commit MMWR Recomm Rep 2005;54:1-31. 19. rivalent human papillomavirus vaccine: recom mendations of the Advisory Committee on Immu MMWR Recomm Rep 2007;56:1-24. 20. Centers of Disease Control and Prevention. FDA li censure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advi MMWR Morb Mortal Wkly Rep 2010;59:626-629. 21. Centers of Disease Control and Prevention. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immu MMWR Morb Mortal Wkly Rep 2010;59:630-632. 22. papillomavirus vaccination: recommendations of tices (ACIP). MMWR Recomm Rep 2014;63:1-30.

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74 http://www.cs.amedd.army.mil/amedd_journal.aspx 23. 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the MMWR Morb Mortal Wkly Rep 2015;64:300-304. 24. 2-dose schedule for human papillomavirus vacci MMWR Morb Mortal Wkly Rep 2016;65:1405-1408. 25. Kim DK, Bridges CB, Harriman KH. Advisory MMWR Morb Mortal Wkly Rep 2016;65:88-90. 26. tribution in high-grade cervical lesions: assessing Cancer Epi demiol Biomarkers Prev 2015;24:393-399. 27. Viens LJ. Human papillomavirusassociated can MMWR Morb Mortal Wkly Rep 2016;65. 28. 9-valent HPV vaccine against infection and in traepithelial neoplasia in women. N Engl J Med 2015;372:711-723. 29. 2004-2008. MMWR Morb Mortal Wkly Rep 2012;61:258-261. 30. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. Na tional, regional, state, and selected local area vac cination coverage among adolescents aged 13-17 MMWR Morb Mortal Wkly Rep 2016;65:850-858. 31. Adams M, Jasani B, Fiander A. Prophylactic HPV vaccination for women over 18 years of age. Vac cine 2009;27:3391-3394. 32. ed States, 2005-2006. J Infect Dis 2016;213:191-198. 33. ness of human papillomavirus vaccine catch-up programs for women. J Infect Dis 2015;211:172-174. 34. Burger EA, Sy S, Nygrd M, et al. Too late to vac tiveness of a delayed catch-up program using the 4-valent human papillomavirus vaccine in Norway. J Infect Dis 2015;211:206-215. 35. MMWR Morb Mortal Wkly Rep 2015;64:95-102. 36. lance of vaccination coverage among adult popula MMWR Surveill Summ 2016;65:1-36. 37. Forbes GB, Brown MR, Welle SL, et al. Hor monal response to overfeeding. Am J Clin Nutr 1989;49:608-611. 38. Bureau of Medicine and Surgery. BUMED Notice 6230: Recommendations for the Use of Quadriva lent and Bivalent Human Papilloma Virus Vac cines in the Navy and Marine Corps December 10, 2012. Available at: http://www.med.navy.mil/ sites/nmcphc/Documents/nepmu-6/Epidemiol ary 23, 2018. 39. DoD Instruction 1010.10: Health Promotion and Disease Prevention partment of Defense; April 28, 2014. Available at: http://www.esd.whs.mil/Portals/54/Documents /DD/issuances/dodi/101010p.PDF?ver=2018 -01-12-113645-193. Accessed February 23, 2018. 40. erage level of 3 doses of human papillomavirus (HPV) vaccine for females and males by age 13 to page, HealthyPeople.gov web site. Available at: https://www.healthypeople.gov/2020/topics-objec objectives. Accessed February 28, 2018. 41. DiGiulio S. All 69 NCI-designated cancer centers issue joint statement on HPV vaccine. Oncol Times 2016;38:14. Available at: https://journals.lww.com/ oncology-times/Citation/2016/03100/All_69_NCI_ Designated_Cancer_Centers_Issue_Joint.5.aspx. Accessed February 23, 2018. 42. LaRocque JD, Berry-Caban CS. Human papil loma virus vaccination coverage among Soldiers in a military treatment facility, 2007-2010. J Vac cines Vaccin. 2011;2(1):116. Available at: https://doi. org/10.4172/2157-7560.1000116. Accessed Febru ary 23, 2018. 43. Shen-Gunther J, Shank JJ, Ta V. Gardasil HPV vaccination: surveillance of vaccine usage and ad herence in a military population. Gynecol Oncol 2011;123:272-277. 44. Dunne EF, Stokley S, Chen WW, et al. human pap illomavirus vaccination of females in a large health J Adolesc Health 2015;56:408-413. 45. Clarke MA, Coutinho F, Phelan-Emrick DF, et al. Predictors of human papillomavirus vaccination in a large clinical population of males aged 11 to 26 years in Maryland, 2012-2013. Cancer Epidemiol Biomarkers Prev 2016;25:351-358. MISSED OPPORTUNITIES IN HUMAN PAPILLOMAVIRUS VACCINATION UPTAKE AMONG US AIR FORCE RECRUITS, 2009-2015

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January June 2018 75 46. Wedel S, Navarrete R, Burkard JF, et al. Im proving human papillomavirus vaccinations in military women. Mil Med 2016;181:1224-1227. AUTHORS ate-Georgia, Walter Reed Institute of Research, Silver Spring, Maryland. Ms Lay is Chief, Department of Health Systems, Preven tive Medicine Branch, Walter Reed Institute of Research, Silver Spring, Maryland. Healthcare Branch, Defense Health Agency, Joint Base San Antonio-Lackland, San Antonio, Texas. Dr Levin is Senior Epidemiologist, Department of Epi demiology, Preventive Medicine Branch, Walter Reed Institute of Research, Silver Spring, Maryland.

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76 http://www.cs.amedd.army.mil/amedd_journal.aspx Much of the world faces a growing obesity epidemic. 1,2(pp92-97) The consequences of this serious prob lem are well established and potentially devastating. Conditions associated with an elevated body mass in clude diabetes, hypertension, coronary heart disease, and certain malignancies. 2(pp97-100),3 For many, obesity and elevated body mass are a consequence of decreased physical activity; industrial advancements (eg, conve nient transportation, technological advancements, and decreased need for manual labor) have contributed to an overall decrease in physical activity worldwide. 4 Multiple studies have examined the reasons for becom ing physically inactive, as well as the perceived barriers to activity and overall wellness. 5-10 Common barriers in clude lack of time, inexperience with exercise, and lack of motivation. 5,6,8-10 Although barriers to wellness and can itself be an obstacle to good health. Healthcare pro viders often have nontraditional work schedules and cite their challenging schedule as a barrier to healthy behavior. 8 States, as the American workweek for all industries is tries and employees are more likely to work odd and/or weekend hours. 11 Long shifts, odd hours, and atypical schedules that are common among healthcare workers are barriers that logically detract from their ability to be physically active, beyond that which is required for their employment. Before policy change can occur, leaders must under in various settings, including corporate and healthcare worksites, but there is sparse evidence about how barri 8,12 Military hospitals are unique in that employees may be active duty military members, civilian employees, or contrac In order to better inform military hospital leadership, the purposes of this study were to describe the common barriers to physical activity for employees at a military hospital, and investigate the association of barriers to physical activity with subjects perception of personal health status. METHODS The health promotion team at a 42-bed military hospi ciaries investigated current barriers to physical, nutri tional, and spiritual wellness as part of the development of an employee wellness program. In the summer of 2014, the team designed a survey to gather this informa tion in partnership with the Army Public Health Center (APHC). The Injury Prevention Division at the APHC designed the electronic survey using Verint Enterprise Edition software (Melville, NY) and provided a secure link through which employees could access the survey. The study was approved by the APHC Public Health Review Board as public health practice and a data use agreement was formally put in place between the hospi tal team and APHC. The study was later presented to the Carolina, which concurred that the investigation did not constitute human research. The survey was intended to be inclusive of all hospital employees. There were no prerequisites to completing the survey and participation was anonymous and op tional. 13 Availability of the survey was announced via digital daily announcements, verbal advertisement to ber 2014. In order to gain a true perspective of the holistic well ness state of hospital employees, subject matter experts Barriers to Physical Activity Among Military Hospital Employees Darren Hearn, DPT, MPH Anna Schuh-Renner, PhD Michelle Canham-Chervak, PhD, MPH Lori Evarts, MPH As of November 2014: 420 (37%) active duty military personnel, 727 (63%) Department of the Army civilian employees.

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January June 2018 77 in the hospital from public health, physical therapy, di etetics, social work, and religious departments submit ted survey questions related to wellness. Although the focus of this article is on responses regarding barriers to physical activity and perceived health, the survey in cluded 49 total questions regarding health behaviors and obstacles to wellness. The survey team took measures to be as inclusive as about barriers to healthy behaviors, respondents were instructed to mark all barriers that applied to them. The survey contained predetermined response options with an other category to capture write-in responses. To not presented to the participant if it was appropriate for that person to skip those questions, based on previous responses. The average time to complete the survey was 17 minutes. Following survey closure, researchers cleaned the data pants marked other. From January through March of lineated by military rank, and healthcare occupational barriers to physical activity were highlighted along with the percentage of respondents who level of physical activity. Chi-square analysis was performed on individu al barriers to physical activity with the dichoto This variable was determined by the answer to the required question Do you perceive yourself as being healthy? with the possible answers of Yes or No. Statistical tests of factors associ ated with perceived lack of health (ie, no re sponses) were evaluated at the alpha 0.05 level. ed, examining the association of the number of reported barriers with the dichotomous depen dent variable of perceived health. The number of variables was a count based on the number of af asked about various types of barriers. Finally, multiple logistic regression was per formed to assess the relationship between a greater number of barriers and perceived health, control ling for demographic variables that were found to be associated with perceived health in the previ ous univariate logistic regression analyses. RESULTS The survey population (N=380) was primarily government civilians (Table 1). There was minor representation of government contractors and retired military serving as hospital volunteers, subgroups: women (56%); age group 26-39 years (47%); and government civilians (45%). The Table 1 Demographics of Survey Respondents (N =380 ). Demographic Military Personnel n 1 = 205 (%n 1 ) DOA Civilian Employees n 2 =169 (%n 2 ) Other n 3 =6 (%n 3 ) All Respondents N= 380 (%N ) Sex Female 71 (35%) 141 (83%) 2 (33%) 214 (56%) Male 134 (65%) 28 (17%) 4 (67%) 166 (44%) Age, years 18-25 32 (16%) 1 (1%) 1 (17%) 34 (9%) 26-39 109 (53%) 34 (20%) 2 (33%) 145 (47%) 40-54 61 (30%) 76 (45%) 1 (17%) 138 (36%) 55 or older 3 (2%) 58 (34%) 2 (33%) 63 (17%) Military Affiliation Enlisted 118 (58%) 118 (31%) Officer 87 (42%) 87 (23%) DOA civilian 169 (100%) 169 (45%) Other 6 (100%) 6 (2%) Education High school or GED 49 (24%) 37 (22%) 86 (23%) Associates 39 (19%) 41 (24%) 80 (21%) Bachelors 42 (21%) 39 (23%) 2 (33%) 83 (22%) Masters or Doctorate 65 (32%) 33 (20%) 4 (67%) 102 (27%) Other professional degree 10 (5%) 19 (11%) 29 (8%) Occupation Nurse 31 (15%) 30 (18%) 61 (16%) Physician 22 (11%) 1 (1%) 23 (6%) Medic 47 (23%) 3 (2%) 50 (13%) Technician 18 (9%) 19 (11%) 1 (17%) 38 (10%) Pharmacy 3 (2%) 5 (3%) 8 (2%) Other medical profession 62 (30%) 13 (8%) 2 (33%) 77 (20%) Administration 14 (7%) 39 (23%) 53 (14%) Other nonmedical or unspecified 8 (4%) 59 (35%) 3 (50%) 70 (18%) DOA indicates Department of the Army. Contract employees and volunteers (retired military). This category includes clinical providers who could not be grouped into broad categories (eg, behavioral health professionals, physical therapists, and dentists).

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78 http://www.cs.amedd.army.mil/amedd_journal.aspx 86% of those surveyed employed in direct clinical care. Ninety percent of respondents considered themselves to be healthy, and of those who considered themselves to be unhealthy (n=38), 95% were interested in becoming healthier. Although the survey population largely con sidered itself to be healthy, many respondents reported unhealthy behaviors such as not enough exercise and 58%) indicated that they did not get enough exercise and 158 participants (42%) responded that they were either cal activity and exercise. As reported by Schuh-Renner et al, 14 47% of respondents reported at least one injury in the previous 12 months. Active duty military members had greater risk for injury, and activities associated with injuries in this population were similar to those in other military populations (physical training, walking/hiking, and lifting or moving objects). Despite a long list of possible barriers from which to choose and the freedom to select multiple barriers, as shown in Table 2, the top 3 barriers were nearly twice as prevalent among respondents as all others. Lack of time was common to 65% of participants and lack of motiva medical condition was reported as a barrier in just over a quarter (27%) of all participants. Those citing pain/other and discomfort with the gym crowd as barriers to physi cal activity were more likely to perceive themselves as unhealthy, as 26%, 26%, 25%, and 22% of respondents citing those barriers, respectively, reported perceived medical conditions and lack of experience as barriers to den and being uncomfortable with the gym crowd. Participants also answered questions about aspects of the work environment and available health promotion activities that might improve their physical activity lev els. Almost two-thirds of participants (n=243, 64%) in exercise would improve their physical activity, an aspect nearly 3 times as important as any other as shown in the Figure. This illustrates the importance of time to employees and how closely they associate personal time with their ability to be physically active. Incentives and access to personal trainers, 2 potential factors to im prove motivation, were cited as being the next 2 most important aspects that would improve physical activity. Percentage of Study Participants Providing a Response Enlisted All Employees Civilian Increased access to personal trainers Incentive Increased access to group classes Increased access to exercise facilities Child care during workout hours More indoor facilities Beginners only time at the gym Increased access to running trails Formation of exercise clubs Other None 20 10 0 40 30 60 50 80 90 70 Reported aspects that would improve physical activity among hospital staff by military status (N= 380 ; multiple responses allowed). BARRIERS TO PHYSICAL ACTIVITY AMONG MILITARY HOSPITAL EMPLOYEES

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January June 2018 79 outlook on physical activity. The sample population indicated that education topic of greatest interest. However, the follow-on questions indicated that nearly 65% of partici pants anticipated that lack of time would be a barrier to attending health education classes. Respondents who reported a previous medical condi tion, lack of experience with exercis physical activity were more likely to also report a perceived lack of health (26%, 26%, and 25%, respectively), as shown in Table 2. ers showed correlation to lack of per ceived health, the overall number of barriers an individual experienced was examined as another potential factor related to perceived lack of sis showed higher odds ratios with increasing number of barriers indicated (Table 3). This result was statisti ( P female gender, and civilian employee status) were also lack of health ( P Multiple logistic regression analysis was performed univariate analyses. The presence of 4 or more barriers factor associated with respondents perception of health ( P =.04), as shown in Table 4. CO MM ENT Addressing the obesity epidemic is paramount in pre venting devastating disease processes and decreasing barriers to physical activity is a key component of pre vention. Previous studies have found that lack of time, motivation, and knowledge are barriers to an individu als wellness, 5,6,8-10 but there is little evidence available about barriers to physical activity among employees of a military medical facility, given the unique aspects of perceived wellness of military medical facility employ ees. Additionally, survey participants indicated that they would change aspects of their environment that directly related to these same barriers, if possible, including exercise facilities. Furthermore, the current analyses ability to be physically active, but employees anticipate wellness education sessions. pation in physical activity, but are also correlated with perception of ones own health. Regression analysis con trolling for demographic characteristics indicated that if ticipation in physical activity, they were 9 times more likely to perceive themselves as unhealthy. While this Additional research examining the combinations of per ceived barriers to physical activity would increase un The active duty military members in this population (54% of respondents) face unique challenges. The highly transient life of most military personnel often leads to greater distances between the Soldier and family mem bers and traditional social support networks. Further datory attendance at unit physical training activities, and additional military duties lead to unique challenges for military providers when compared to traditional Table 2 Barriers to Physical Activity and Perceived Lack of Health (N= 380 multiple responses were allowed). Barrier to Physical Activity All Respondents N=380 n 1 (%N ) Enlisted n 2 = 118 (%n 2 ) n 3 = 87 (%n 3 ) Civilian n 4 = 175 (%n 4 ) Respondents Reporting Lack of Health (%n 1 ) Lack of time 247 (65%) 65 (55%) 70 (80%) 112 (64%) 21 (9%) Lack of motivation 171 (45%) 49 (42%) 24 (28%) 98 (56%) 21 (12%) Pain or previous medical condition 104 (27%) 39 (33%) 18 (21%) 47 (27%) 27 (26%) Not comfortable with gym crowd 58 (15%) 12 (10%) 7 (8%) 39 (22%) 13 (22%) Lack of support network 54 (14%) 14 (12%) 9 (10%) 31 (18%) 8 (15%) Weather 54 (14%) 16 (13%) 17 (20%) 21 (12%) 8 (15%) No child care 46 (12%) 16 (14%) 14 (16%) 16 (9%) 4 (9%) Financial burden 20 (5%) 1 (1%) 0 (0%) 19 (11%) 5 (25%) Lack of experience or knowledge 19 (5%) 9 (8%) 1 (1%) 9 (5%) 5 (26%) Work 11 (3%) 2 (2%) 6 (7%) 3 (2%) 1 (9%) No parking at gym 0 (0%) Other 16 (4%) 2 (2%) 4 (5%) 10 (6%) 1 (6%) None 32 (9%) 19 (16%) 3 (3%) 10 (6%) 1 (3%) Total (n 4 ) includes 169 Department of the Army civilian employees and 6 contract employees or hospital volunteers.

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80 http://www.cs.amedd.army.mil/amedd_journal.aspx results indicate that barriers common to other popula tions (lack of time and motivation) exist in a military medical facility. Additionally, these very same barri ers are statistically related to the employees perceived health, giving more credence to the idea that barriers must be addressed in a fashion that is meaningful to the individual. Recommendations from the American Heart Association state that employers should seek to reduce or eliminate barriers that discourage use of worksite wellness programs. 15 Further research those barriers. Since workplaces are now taking more prominent roles in advancing the health of their employees, 16 barriers to participating in wellness activities and their impact on the overall health of employees. Large multinational corporations like Google are ness centers and multiple opportunities for physi cal activity. 17 The need to eliminate these barriers is necessary not simply to enhance the employee decreased healthcare costs, increased productiv ity, improved morale, increased retention, and de creased absenteeism. As Baicker and colleagues 18 explain, savings are not simply associated with decreased healthcare costs; rather, additional rev enue is appreciated when workers are present and well. Decreased absenteeism, for example, allows workers to focus on their own productivity, rather than making up for the work not completed by an absent colleague. Baicker et al found that the return on investment in wellness programs was $3.27 for every dollar spent through decreased healthcare cost and $2.73 for every dollar spent through decreased absenteeism. 18 This study had some limitations. With approxi mately 32% of the hospital population respond ing to the survey, it is possible that those who responded did not represent the entire population. The people who were interested enough in well barriers than those who chose not to participate. of health may have led to a decreased ability to to draw statistically sound conclusions from the data. With only 10% of individuals reporting themselves to be unhealthy, there may not have been enough power to assess the correlation of all barriers with perceived health. In future studies, the use of a Likert scale may assessed health metrics. Table 3 Injury Incidence: Factors Associated with Perceived Lack of Health (N= 380 ). Variable Total in Variable Category n 1 Perceived Lack of Health n 2 (%n 1 ) Odds Ratio ( 95% CI ) P Value Number of Barriers to Physical Activity 0 39 1 (3%) 1.00 1 108 7 (6%) 2.53 (0.32-19.89) .36 2 102 9 (9%) 3.44 (0.45-26.27) .20 3 79 8 (10%) 3.95 (0.51-30.47) .15 4 or more 52 13 (25%) 9.75 (1.33-71.40) <.01 Age, years 18-25 34 1 (3%) 1.00 26-39 145 10 (7%) 2.35 (0.31-17.70) .39 40-54 138 16 (12%) 3.94 (0.54-28.69) .13 55 or older 63 11 (17%) 5.94 (0.80-44.04) .04 Sex Female 214 27 (13%) 1.90 (0.97-3.73) .05 Male 166 11 (6%) 1.00 Military Affiliation Enlisted 118 8 (7%) 1.48 (0.46-4.74) .51 Officer 87 4 (5%) 1.00 DOA civilian 169 25 (15%) 3.22 (1.16-8.95) .01 Other 6 1 (17%) 5.44 (0.77-38.16) .08 Education High school or GED 86 9 (10%) 1.30 (0.53-3.24) .57 Associates 80 9 (11%) 1.43 (0.58-14.53) .43 Bachelors 83 9 (11%) 1.38 (0.56-3.43) .48 Masters or Doctorate 102 8 (8%) 1.00 Other professional degree 29 3 (10%) 1.32 (0.37-4.66) .67 Occupation Nurse 61 6 (10%) 0.98 (0.35-2.77) .98 Physician 23 0 0 .12 Medic 50 3 (6%) 0.60 (0.16-2.21) .44 Technician 38 5 (13%) 1.32 (0.45-3.87) .62 Pharmacy 8 1 (13%) 1.25 (0.18-8.90) .83 Other medical profession 77 6 (8%) 0.78 (0.28-2.21) .64 Administration 53 10 (19%) 1.89 (0.77-4.63) .16 Other nonmedical or unspecified 70 7 (10%) 1.00 DOA indicates Department of the Army. Contract employees and volunteers (retired military). This category includes clinical providers who could not be grouped into broad categories (eg, behavioral health professionals, physical therapists, and dentists). BARRIERS TO PHYSICAL ACTIVITY AMONG MILITARY HOSPITAL EMPLOYEES

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January June 2018 81 Approaches to improving barriers to physical activity, including environmental changes, are necessary to facil itate an environment of disease, injury, and obesity pre vention. Institutional leaders should continue to explore programs that investigate and address common barriers to physical activity. Leaders in military hospitals should consider programs that promote the principles of the program that intends to make healthy living the easier choice and social norm.... 19 Policies that address barriers other military workplaces. 20 Agreements between lead ership and employees facilitate participation in exercise activities, but also require consistent documentation of the workouts, approved routines, and health clearances to continue participation. A cultural change that embrac es physical activity and encourages it as a part of each day would be a useful step toward preventing chronic disease processes among military healthcare employees. The analysis and reporting of the successes and failures tionally, and physically for many in our communities. REFERENCES 1. ell MA, Tabak CJ, Flegal KM. Prevalence of 1999-2004. JAMA 2006;295(13):1549-1555. doi:10.1001/jama.295.13.1549. 2. Institute of Medicine Committee on Health and Behavior: Research, Practice, and Policy. Health and Behavior: The Interplay of Biologi Wash ington, DC: National Academies Press; 2001. Available at: http://www.ncbi.nlm.nih.gov/ books/NBK43743/. Accessed June 21, 2015. 3. iology and consequences of obesity. Obes Res 2002;10(S12):97S-104S. doi:10.1038/oby.2002. 202. 4. Harvard T.H. Chan School of Public Health. ty; 2015. Available at: http://www.hsph.harvard. edu/obesity-prevention-source/obesity-causes/ physical-activity-and-obesity/. Accessed No vember 22, 2015. 5. Bautista L, Reininger B, Gay JL, Barroso CS, McCormick JB. Perceived barriers to exercise in hispanic adults by level of activity. J Phys Act Health 2011;8(7):916. 6. H. Barriers to participation in physical activity and exercise among middle-aged and elderly individu als. Singapore Med J 2013;54(10):581-586. 7. policy and environmental interventions that pro mote physical activity and nutrition for cardiovas cular health: what works?. Am J Health Promot 2005;19(3):167-193. 8. Phiri LP, Draper CE, Lambert EV, Kolbe-Alexan der TL. Nurses lifestyle behaviours, health priori ties and barriers to living a healthy lifestyle: a qual itative descriptive study. BMC Nurs 2014;13(1):38. Available at: https://bmcnurs.biomedcentral.com/ articles/10.1186/s12912-014-0038-6. Accessed Feb ruary 1, 2018. 9. Sjrs C, Bonn SE, Lagerros YT, Sjlander A, Bl ter K. Perceived reasons, incentives, and barriers to physical activity in Swedish elderly men. Interact J Med Res 2014;3(4):e15. doi:10.2196/ijmr.3191. 10. W. Correlates of adults participation in physical activity: review and update. Med Sci Sports Exerc 2002;34(12):1996-2001. Table 4 Multivariable Logistic Regression Results: Factors Associ ated with Perceived Lack of Health (N= 380 ). Variable Total in Variable Category n 1 Perceived Lack of Health n 2 (%n 1 ) Risk Ratio (95% CI ) P Value Number of Barriers to Physical Activity 0 39 1 (3%) 1.00 1 108 7 (6%) 2.05 (0.24-17.66) .51 2 102 9 (9%) 3.06 (0.37-25.88) .30 3 79 8 (10%) 3.51 (0.42-25.88) .25 4 or more 52 13 (25%) 9.46 (1.14-78.66) .04 Age, years 18-25 34 1 (3%) 1.00 26-39 145 10 (7%) 2.76 (0.32-24.02) .36 40-54 138 16 (12%) 4.45 (0.49-40.80) .19 55 or older 63 11 (17%) 6.79 (0.66-70.06) .11 Sex Female 214 27 (13%) 1.34 (0.55-3.27) .53 Male 166 11 (6%) 1.00 Military Affiliation Enlisted 118 8 (7%) 2.21 (0.59-8.28) .24 Officer 87 4 (5%) 1.00 DOA civilian 169 25 (15%) 2.08 (0.62-6.94) .23 Other 6 1 (17%) 3.45 (0.25-46.66) .35 DOA indicates Department of the Army. Contract employees and volunteers (retired military).

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82 http://www.cs.amedd.army.mil/amedd_journal.aspx 11. Hamermesh DS, Stancanelli E. Long Workweeks and Strange Hours [internet]. Cambridge, MA: Na tional Bureau of Economic Research; 2014. Avail able at: http://www.nber.org/papers/w20449.pdf. Accessed November 22, 2015. 12. Blackford K, Jancey J, Howat P, Ledger M, Lee tervention: barriers, enablers, and preferred strate gies for workplace obesity prevention, Perth, West ern Australia, 2012 [internet]. Prev Chronic Dis 2013;10:E154. Available at: https://www.cdc.gov/ pcd/issues/2013/13_0029.htm. Accessed February 1, 2018. 13. Schuh A, Canham-Chervak M. Technical Report No. S.0032417-16: Assessment of Health Behaviors, Health Education Interests, and Injuries among Employees at the General Leonard Wood Army Community Hospital, October 2014-December 2014 Public Health Center; 2016. Available at: www.dtic. mil/get-tr-doc/pdf?AD=ADA633025. Accessed February 1, 2018. 14. Schuh-Renner A, Canham-Chervak M, Hearn DW, Loveless PA, Jones BH. Factors Associated With Workplace Health Saf December 14, 2017 (epub ahead of print). Available at: http://journals.sage pub.com/doi/10.1177/2165079917736069. Accessed February 1, 2018. 15. Carnethon M, Whitsel LP, Franklin BA, et al. Worksite wellness programs for cardiovascu lar disease prevention: a policy statement from the American Heart Association. Circulation 2009;120(17):1725-1741. 16. Sorensen G, Stoddard A, Peterson K, et al. Increas ing fruit and vegetable consumption through work sites and families in the treatwell 5-a-day study. Am J Public Health 1999;89(1):54-60. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1508509/. Accessed November 19, 2015. 17. Athletic Business. Corporate Fitness Centers In creasing Across the Nation [internet]. Available at: corporate-fitness-centers-increasing-across-thenation.html. Published June 2015. Accessed No vember 22, 2015. 18. Baicker K, Cutler D, Song Z. Workplace Well ness Programs Can Generate Savings. Health (Millwood). 2010;29(2):304-311. Available at: https://www.healthaffairs.org/doi/pdf/10.1377/ 19. ternet]. Available at: http://www.health.mil/Mili January 7, 2016. 20. Close K. Civilian Wellness Letter and Fitness Pro Air Logistics Center; May 12, 2009. Available AFMC%20Civilian%20Wellness%20Letter_0.pdf. Accessed January 7, 2016. AUTHORS student in the Human Movement Science Curriculum at Dr SchuhRenner and Dr Canham-Chervak are with Center, Aberdeen Proving Ground, MD. Ms Hodges is with Prevention Partners, Chapel Hill, NC. Ms Evarts is with the Gillings School of Global Public BARRIERS TO PHYSICAL ACTIVITY AMONG MILITARY HOSPITAL EMPLOYEES ARMY MEDICINE One TeamOne Purpose! Conserving the Fighting Strength Since 1775

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January June 2018 83 Women have always played a crucial role in the sup port of our nations military, directly and indirectly. Not until recently, however, have women been allowed to serve in unrestricted roles. Prior to 1993, women were not permitted to serve on combatant aircraft, vessels, or of outdated policy allowed women into the aforemen tioned roles including combat units, generating the need for review of occupational standards and assignment announced approval for women to be assigned to direct ground combat roles, including all military services and 1 With the unprec edented expansion of womens role in combat combined with the longest period of continuous active combat in 2 it is time that research be expanded to in clude the nutritional and hydration requirements of our female tactical athletes. fessionals that require expertise in their occupational skills concomitant with general physical preparedness, which enable them to perform physically demanding occupational tasks while mitigating injury. 3 These tac tical professionals are required to possess physical and athletes becomes the explicit requirement of baseline ment of confronting and overcoming physical, environ mental, and human threats with little to no advanced notice setting them apart from civilian athletes. While traditional players train and compete in seasons, those considered tactical know their position requires them to operate in season constantly. Anything short of optimal performance for any tacti However, performance for a new recruit plays a vital role in acceptance and integration into their new unit in addition to survival. An assessment of these guidelines will further facilitate female integration and acceptance by their new team. As combat is frequently in austere conditions and physically demanding, hydration status and strategies are paramount. Not only is hydration cru of dehydration, as the result can be lethal. This review focuses on what is known in the literature regarding hy formance while avoiding exercise-related illness, and a call for further research in the developing group of fe male tactical athletes. DELETERIOUS EFFECTS OF DEHYDRATION Water is essential to life down to the cellular level. With out it our species can survive mere days. The lack of a nature of our regulatory systems. It is understood as the process of uncompensated water loss via urine, sweat, feces, and respiratory vapor thus reducing total body water below the average basal value. 4-9 However, amongst those who strive to measure hydration status the accepted value is 2% loss in body weight during ac route. Components that lead to dehydration can be bro ken into categories such as lack of access, physiologic loss, and environmental stressors. Access pertains to Hydration Strategies for the Female Tactical Athlete ABSTRACT With unprecedented expansion of the roles of women in the military and the longest period of continuous active intensity, aerobic endurance activities. There is evidence female athletes may be more prone to the potentially optimal hydration strategies for the female tactical athlete.

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84 http://www.cs.amedd.army.mil/amedd_journal.aspx the delay in rehydration. 10-12 Physiologic losses are main variations of intake and output. Regarding these mea sures in the context of rigorous training, the bodys re nal, hypothalamic, and neurologic control can be taxed to their extremes in a matter of hours. 13 Lastly, and the hardest to control, the environmental factors of ambient temperature, humidity, altitude, air currents, and cloth ing 14 water loss. Battle dress uniform and body armor add a minimum of 5F to the ambient temperature. 15 When envisioning both the training and operations of tactical athletes, the austerity of their locations often impose physical, behavioral, and environmental conditions be yond the bounds of homeostatic norms and demand an It is well documented that dehydration has a negative 16,17 dehydration is the loss of 2% body weight, athletes have been documented to have up to 6% to 10% losses or more in rare cases. 18 individuals engaging in rigorous physical activity, even in temperate climates, will experience decrements in performance due to altered thermoregulatory capability, compromised cardiovascular function, and increased fatigue, resulting in reduced endurance, reduced moti 5 Inadequate hy high intensity, 19 aerobic, 20-22 endurance activities such as long-distance running, 23 as well as decrements in ac curacy 24,25 with even larger scope application of nega demand high levels of skill and precision. 21 Assessment outcomes such as reduced accuracy, speed of complex tasks, and distance judgement were also negatively 24,26-32 It is less clear to what degree dehydration worsens cog nition originally suggested by Sharma and Gopinathan separately in 1986 and 1988 respectively. 33,34 Lieberman hypohydration on cognition was rather equivocal until ing consistent levels of dehydration that do not confound with the stressors used to get there, and our inability to accurately and reliably measure hydration status from moment to moment in addition to our limitations on cognitive measure itself. 35 Research shows that concen tration, alertness, and short term memory all decrease while dehydrated. 29,31,35-37 This is in addition to the well 31 and alert ness that can be subjectively improved by hydrating. 37 DELETERIOUS EFFECTS OF OVERHYDRATION performance, so too can the consequences of drinking strategy, has shown to be an illegitimate solution to de hydration. 29 to enhance performance, in either gender, by intentional overhydration. Whatever the marginal competitive ad vantage may be, it does not outweigh the risks. These risks have been recorded in endurance athletes, hikers, death. In the wake of a military training-related death, 38 found to be successful. 15 By reducing the incidence of risk of dehydration, Kolka et al 15 proposed safer hydrat ing strategies for strenuous training and expanded the guidelines including female subjects previously unavail able. Similarly, the increasingly high numbers of serious illness and death in female athletes in the last quarter hydrating. In an attempt to prevent heat injury, these en durance athletes are increasing their risk of hyponatre as more than 135 mmol/L of sodium and is associated with a number of sodium and water disorders. 39 Perhaps the most concerning risk is the similarity in presentation of acute overhydration to the antithesis symptomatic de hydration. Mistaking one diagnosis for the other can be devastating, as was demonstrated in the incident of the military trainee; the symptoms of altered mental status, emesis, and nausea were interpreted and treated as if a common case of dehydration or heat-related illness and treated as would have been appropriate for dehydration. Instead, however, his hyponatremia worsened with the treatment for dehydration, and as a result, he died due to irreversible damage of the brain and lungs. 38,40 Another the fact that research shows women are more compliant be seen as an advantage; however, research at the other extreme of the spectrum found that female athletes are 25 times more likely to die from hyponatremia during an endurance race. 41 These unfortunate events indicate the need for further research and continued education within the athletic community. HOW TO ASSESS HYDRATION STATUS There are many proposed techniques for measuring hy dration status in athletes. To date, there is no one bio marker that is accepted as the gold standard indicator of HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE

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January June 2018 85 hydration. After all, euhydration is the concept of the dards should be sensitive and accurate enough to detect minimally invasive, inexpensive, mobile, expedient, easy to use and require little training. All modern tools hinge around singular measures of the highly dynamic strong 42 contrasts the importance of accuracy in labora ment techniques reviewed for this article included thirst, change in body weight, sweat volume, urine osmolality, pedance analysis, among others. 20,30,42-46 and water lost. Daily sources of water include beverages (81%), food (19%), 20 and metabolic production (a negli gible volume in comparison, and approximately equal 47,48 Water is lost through respiratory, gastrointestinal, renal, and sweat functions. 49 Total body water can be estimated using tracer methods, most commonly deuterium oxide, with an accuracy of 1% to 2%. 8,43 This is the most valid 50 How ever, as functional dehydration is 2% or greater body weight (BW) change, this margin of error meets the sen sitivity requirement but does not outdo simply tracking ences in body composition also make tracer methods a suboptimal technique for operational tactical athletes. 20 As sweating is the primary avenue of water loss during exercise-heat stress, acute changes in body weight can be used to calculate an athletes sweat rate. 51 Following the equation used in the 2000 National Athletic Train ers Association Position Statement, each athlete can, and should, calculate their individual sweat rate: (sweat urine volume)/exercise time in hours. Sweat rates found in the literature range from 0.5 L/h to more than 4 L/h (0.50 kg/h to 4 kg/h) 5,14,49 with conclusive evidence that, in general, females sweat less than males. 52 As sweat rates vary drastically due to individual metabolic and cise, and environmental factors, it is imperative that ath letes begin to consider hydration with the same regard as nutrition. Many argue that water is in fact the prin cipal nutrient, more important than sources of fuel. It is advised that athletes, be it an individual or as a team for an average, calculate their sweat rate in various envi ronmental conditions as well as periodically account for Without a gold standard, a single assessment technique is inadequate to evaluate body hydration status. There fore, combining several techniques for multiple points of reference is encouraged. After consideration of bar riers such as time required, cost, portability, ease of use, etc, the recommendation is to combine BW changes with urine indices. Body weight measurement should be postvoid but premeal and with as few confounding ar ticles of clothing as possible. A baseline value can be es tablished with at least 3 consecutive morning nude BW measures to approximate euhydration if athletes have 53 Female athletes may require additional BW measurements as menstrual 49,54,55 When acute water losses are estimated by preand postexercise BW measures, consideration should be made for sweat trapped in clothing. 56 Body weight mea sures with calculated percentage of body weight change should be conducted before, during (if exercise exceeds balance. 5 Pre-exercise urine biomarkers can allow discrimination between euhydration and dehydration. 9,57,58 mol) together provide the most insight to an athletes hy ing euhydrated. 57-59 euhydration. 9,57,58 refractometer should be done on midstream samples preif obtained during rehydration periods, especially during periods of rapid recovery. Consumption of large volumes 8,58,60 If context considerations are made stacked with consistent BW measures, these techniques provide the most reli methods of assessing hydration status. HYDRATION STRATEGY The athletic community has no problem accepting that hydration is crucial to exercise performance. This ar ticle recommends guidelines consistent with the Ameri can College of Sports Medicine (ACSM) Position Stand 2007 49 with a call for continued research on the topic in the direction of both tactical and female athletes. The history of hydration standards is saturated with

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86 http://www.cs.amedd.army.mil/amedd_journal.aspx misunderstanding. The commonly quoted 8 by 8, eight glasses of 8 ounces of water daily, is best explained as a misinterpretation of the 1945 Food and Nutrition Board Recommendation, which was 2.5 L total water per day and ignoring the phrase that much dietary water comes from food. 20,61 The most recent issue (2005) by the Food and Nutrition Board of the Institute of Medicine (now renamed the National Academy of Medicine), states 2.7 L per day as the adequate intake for women aged 19 to 30 years, the most inclusive age range for tactical athletes. Because euhydration can be maintained over a wide range of water intakes, it is not possible to deter mine an estimated average requirement, and this value data. 20,62 sideration when determining baseline is caloric intake. It is often cited and generally accepted that 1 to 1.5 mL of water should be ingested per kilocalorie consumed. 63 tical athletes. For example, a woman consuming 3,000 kilocalories per day would require 4.5 L of dietary water must be executed in phases of a continuum: preparation, maintenance, recovery with respect to timing of the ath letic event, practice or operation. PREPARATION Hydration before exercise should be at a comfortable and regulation of urine output. 49 Athletes should take note of signs and symptoms of inadequate hydration: dark colored urine or lack of urine production, headache, lightheadedness, or evidence of orthostasis (head-rush or light headedness upon standing from a laying or seated position). 5,64 If any are present, the athlete should cantly with recovery from last exercise), the addition of 65-67 Hyperhydration, with water or glycerol-containing bev erages has not been shown to provide physiologic or performance advantages over euhydration. To the con trary, it increases the risk of lowering athletes plasma sodium, 68,39 therefore increasing the chance of dilutional hyponatremia. The recommendation remains against its use. 69 MAINTENANCE The goal of hydration in the maintenance phase is to re weight loss less than 2%, while retaining electrolyte bal ance. Mathematical analysis of Table 5 in the ACSM Po sition Stand 2007 49 derived projections that proved satis factory for both male and female athletes when looking condition. The upper end of the suggested range of rates is directed towards faster runners with greater BMI, in herently heavier sweaters who are training or operating in warmer environments with the lower suggested rate for the slower, lower BMI, working in cooler conditions. from 0.4 to 0.8L/hour drawn from marathon runners. 49,70 Depending on individual sweat rate, exercise duration all hydration strategy. 71 In this case, athletes will transi tion from preparation directly to recovery. As for what athletes should drink, in 2005 the Institute of Medicine published the recommended composition 20 Fluid vidual as well as culture. Preferred water temperature is found to be between 15C and 21C. The vessel in which the electrolytes are consumed plays a negligible Sources include drinks, gels, energy bars, and other foods. Ingesting carbohydrate in any of these forms al lows the athlete to go harder longer as the provision of carbohydrate decreases the use of stored glycogen. 72-78 A cose 79,80 and are recommended for exercise lasting more than an hour. 73,81-85 While sports beverages provide the allure of rehydrating as well as a source of carbohydrate, athletes are warned against products that have a carbo hydrate concentration greater than 7% as they reduce gastric emptying, the anatomic limiting step to rehydra 86 feine which are thought to help sustain exercise. 87 It is the 24-hour period. 88-90 essary, both of which are not always available to a tacti HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE

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January June 2018 87 the athlete into an acute phase of hypovolemia without the ability to replenish the losses. Casa et al 5 also warns against consumption of alcohol and carbonated bever RECOVERY During the recovery phase, the goal is to fully replace throughout exercise. If recovery time and opportunity permit, common sodium-containing meals and snacks enough to bring the athlete back to baseline. 20 While many focus on water, during any recovery period, fail ure to replace sodium will greatly hamper return to euhydration. In many, if not most situations, tactical athletes will be required to have shortened recovery pe riods. If time between the end of one exercise and the beginning of the next is less than 12 hours, one should consider this a rapid recovery, and steps should be taken to expedite the athletes return to equilibrium. While so tant during this rapid recovery and extra salt in meals 91,92 should be consumed for every kg of body weight lost a faster than normal intake, the body compensates with over longer periods of time as opposed to boluses. 93,94 provide an advantage over oral hydration and electrolyte replacement in the absence of either a dysnatremia 64 or severe dehydration evidenced by greater than 7% body weight loss, nausea, vomiting, or diarrhea. 5 SU MM ARY Very few studies have been done on female athletes or tactical athletes. The overall lack of data on female tac tical athletes in the deployment setting simply points to an area needing further discovery. With the current lit erature, the recommendations in this article are almost might apply the best data available. While superimposi tion might be considered a critique of this review, the of variance in data collection methods and application towards the dynamically imprecise prevents greater external validity. In summary, this article provides the form the foundation of a hydration strategy to prevent heat illness and avoid overhydration injury. It encour ages the combined use of body weight changes sur rounding 3 phases of the hydration continuum: prepara tion, maintenance, and recovery. Included are the latest recommended hydration composition and rate for opti athletes must determine what works best for them as an hydration strategy. As the females role in the military expands, so too should the research pertaining to the needs of female tactical athletes. REFERENCES 1. Burelli DF. Women in Combat: Issues for Congress. Washington, DC: Congressional Research Service; 2013. Available at: http://www.dtic.mil/dtic/tr/full text/u2/a590333.pdf. Accessed January 11, 2018. 2. Butler FK. Two decades of saving lives on the bat Mil Med 2017;182:e1563-e1568. 3. product of 21st century strength and conditioning. Strength Cond J 2015;37:2-7. 4. Armstrong LE. Hydration assessment techniques. Nutr Rev 2005;63:S40-S54. 5. Casa DJ, Armstrong LE, Hillman SK, et al. Nation al Athletic Trainers Association Position State ment: Fluid Replacement for Athletes. J Athl Train 2000;35(2):212-224. Available at: https://www.ncbi. nlm.nih.gov/pmc/articles/PMC1323420/. Accessed January 11, 2018. 6. Kavouras SA. Assessing hydration status. Curr Opin Clin Nutr Metab Care 2002;5:519-524. 7. eters, epidemiology and recommendations. Eur J Clin Nutr 2003;57(suppl 2):S10-S18. 8. Eur J Clin Nutr 2003;57:S6-S9. 9. ity and conductivity as indices of hydration sta tus in athletes in the heat. Med Sci Sports Exerc 1998;30:1598-1602. 10. Rolls B. Homeostatic and non-homeostatic con trols of drinking in humans. In: Arnaud EJ, ed. Hy dration Throughout Life London: John Libbey and Company Ltd; 1998:19-28. 11. Physiol Behav 1989;45,639-647.

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88 http://www.cs.amedd.army.mil/amedd_journal.aspx 12. Matthew WT. Variability in intake and dehydration in young men during a simulated desert walk. Aviat Space Environ Med 1989;60:422-427. 13. Grandjean AC, Reimers KJ, Buyckx ME. Hy dration: issues for the 21st century. Nutr Rev 2003;61:261-271. 14. the heat. In: Marriott BM, ed. Nutritional Needs in Hot Environments: Applications for Military Per sonnel in Field Operations Washington, DC: Na tional Academies Press; 1993:chap 5. Available at: https://www.ncbi.nlm.nih.gov/books/NBK236237/. Accessed January 11, 2018. 15. training in hot weather. Aviat Space Environ Med 2003;74(3):242-246. 16. hydration on skill-based performance. Int J Sports Sci 2015;5(3):99-107. 17. Popkin BM, DAnci KE, Rosenberg IH. Water, hy dration and health. Nutr Rev 2010;68:439-458. 18. ness in athletes: the dangerous combination of heat, humidity and exercise. Sports Med 2004;34(1):9-16. 19. Judelson DA, Maresh CM, Anderson JM, et al. endurance?. Sports Med 2007;37(10):907-921. 20. Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate Washington, DC: National Academies Press; 2005. Available at: https://www.nap.edu/ read/10925/chapter/1. Accessed January 11, 2018. 21. Montain SJ. Hydration recommendations for sport 2008. Curr Sports Med Rep 2008;7:187-192. 22. Sawka MN, Noakes TD. Does dehydration im pair exercise performance?. Med Sci Sports Exerc 2007;39:1209-1217. 23. Cheuvront SN, Montain SJ, Sawka MN. Fluid re placement and performance during the marathon. Sports Med 2007;37:353-357. 24. Baker LB, Dougherty KA, Chow M, Kenney WL. Progressive dehydration causes a progressive de cline in basketball skill performance. Med Sci Sports Exerc 2007;39:1114-1123. 25. Devlin LH, Fraser SF, Barras NS, Hawley JA. Moderate levels of hypohydration impairs bowling accuracy but not bowling velocity in skilled cricket players. J Sci Med Sport 2001;4:179-187. 26. S. Psychomotor deterioration during exposure to heat. Aviat Space Environ Med 1980;51:607-610. 27. Smith MF. The role of physiology in the de velopment of golf performance. Sports Med 2010;40:635-655. 28. mild dehydration on cognitive-motor performance in golf. J Strength Cond Res 2012;26:3075-3080. 29. Cian C, Koulmann N, Barraud P-A, Raphel C, dration, heat stress, and exercise-induced dehydra tion. J Psychophysiol 2012;14:29-36. 30. status and subjective feelings in man. Br J Nutr 2004;91:951-958. 31. nitive-motor performance in healthy men and women. Am J Physiol Regul Integr Comp Physiol 2005;289(1):R275-R280. 32. KM, Prentice WE. Neurophysiological perfor mance, postural stability and symptoms after dehy dration. J Athl Train 2007;42(1):66-75. 33. Gopinathan PM, Pichan G, Sharma VM. Role of dehydration in heat stress-induced variations in mental performance. Arch Environ Health 1988;43:15-17. 34. Sharma VM, Sridharan K, Pichan G, Panwar MR. mental functions. Ergonomics 1986;29:791-799. 35. Lieberman HR. Hydration and human cognition: a critical review and recommendations for future research. Nutr Today 2010;26(suppl 5):555S-561S. 36. Adam GE, Carter R 3rd, Cheuvront SN, et al. Hy military tasks in temperate and cold environments. Physiol Behav 2008;93(4-5):748-756. 37. Neave N, Scholey AB, Emmett JR, Moss M, Ken performance in dehydrated healthy young volun teers. Appetite 2001;37(3):255-256. 38. Garigan TP, Ristedt DE. Death from hyponatremia as a result of acute water intoxication in an Army basic trainee. Mil Med 1999;164:234-238. 39. Glycerol hyperhydration: physiological responses during cold-air exposure. J Appl Physiol (1985). 2005;99:515-521. HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE

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January June 2018 89 40. Khapik JJ, Craig SC. Hyponatremia associated Mil Med 2001;166(5):405-410. 41. Eichner ER. Exertional hyponatremia: why so many women?. Sports Med Digest 2002;24:54-56. 42. Armstrong LE. Assessing hydration status: the elu sive gold standard. J Am Coll Nutr 2007;26(suppl 5):575S-584S. 43. Lohman TG, Wang Z, Going SB, eds. Human Body Composition 2nd ed. Champaign, IL: Human Ki netics; 1996:35-49. 44. Eur J Clin Nutr 2003;57(suppl 2):S6-S9. 45. Singh NR, Peters EM. Markers of hydration status in a 3-day trail running event. J Can Acad Sport Med 2013;23:354-364. 46. with plasma osmolality as a measure of hydration status in male and female NCAA collegiate ath letes. J Strength Cond Res 2016;30(8):2219-2225. 47. Johnson RE, Pecora LJ. Physiological Measure ments of Metabolic Function in Man New York, NY: McGraw-Hill; 1963:313-339. 48. Mitchell JW, Nadel ER, Stolwijk JA. Respira tory weight losses during exercise. J Appl Physiol 1972;32:474-476. 49. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports Medi Med Sci Sports Exerc 2007;39(2):377-390. 50. body composition. In: Arnaud EJ, ed. Hydration Throughout Life London: John Libbey and Com pany Ltd; 1998:63-74. 51. Gosselin RE, Adolph E. Rates of sweating in the desert. In: Adolph EF. Physiology of Man in the Desert New York, NY: Intersciences Publishers, 1947:44-76. 52. Eijsvogels TM, Scholten RR, van Duijnhoven Scand J Med Sci Sports 2013;23(2):198-206. 53. Cheuvront SN, Carter, R, Montain SJ, Sawka MN. Daily body mass variability and stability in active men undergoing exercise-heat stress. Int J Sport Nutr Exerc Metab 2004;14:532-540. 54. Volpe SL, Poule KA, Bland EG. Estimation of pre practice hydration status of National Collegiate Athletic Association Division I athletes. J Athl Train 2009;44:624-629. 55. Bunt JC, Lohman TG, Boileau RA. Impact of to fat from body density. Med Sci Sports Exerc 1989;21:96-100. 56. Cheuvront SN, Haymes EM, Sawka MN. Com parison of sweat loss estimates for women during prolonged high-intensity running. Med Sci Sports Exerc 2002;34:1344-1350. 57. Armstrong LE, Maresh CM, Castellani JW, et al. Int J Sport Nutr 1994;4(3):265-279. 58. and urinary measures of hydration status during progressive acute dehydration. Med Sci Sports Ex erc 2001;33(5):747-753. 59. Bartok, C, Schoeller DA, Sullivan JC, Clark RR, Landry GL. Hydration testing in collegiate wres tlers undergoing hypertonic dehydration. Med Sci Sports Exerc 2004;36:510-517. 60. not accurate measures of hydration status during postexercise rehydration. J Sports Med Phys Fit ness 1999;39:47-53. 61. Vreeman RC, Carroll AE. Medical myths. BMJ 2007;335:1288-1289. 62. Erdman JW. Preface. In: Institute of Medicine. Di etary Reference Intakes for Water, Potassium, So dium, Chloride, and Sulfate Washington, DC: Na tional Academies Press; 2005. Available at: https:// www.nap.edu/read/10925/chapter/1. Accessed Jan uary 11, 2018. 63. Dwyer J. Nutrient requirements and dietary assess ment. In: Longo DL, Fauci AS, Kasper DL, Hauser Harrisons Prin ciples of Internal Medicine 18th ed. New York, NY: McGraw-Hill; 2012:588-594. 64. Sallis RE. Fluid balance and dysnatremias in ath letes. Curr Sports Med Rep 2008;7(4):S14-S19. 65. Eur J Appl Physiol 1996;73:317-325. 66. Ray ML, Bryan MW, Ruden TM, Baier SM, Sharp J Appl Physiol (1985). 1998;85(4):1329-1336. 67. exercise-induced volume depletion in humans: re placement of water and sodium losses. Am J Physi ol 1998;274(5 Pt 2):F868-F875.

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90 http://www.cs.amedd.army.mil/amedd_journal.aspx 68. Freund BJ, Montain SJ, Young AJ, et al. Glyc erol hyperhydration: hormonal, renal, and vas J Appl Physiol (1985). 1995;79(6):2069-2077. 69. hydration on hyperthermia and cardiovascu lar drift during exercise. J Appl Physiol (1985). 1992;73:1340-1350. 70. Montain SJ, Cheuvront SN, Sawka MN. Exercise associated hyponatraemia: quantitative analy sis to understand the aetiology. Br J Sports Med 2006;40(2):98-105;discussion 98-105. 71. habitual hydration strategies of female rugby and blood sodium concentration during training J Strength Cond Res 2016;30:875-880. 72. so J, Coyle EF. Fluid and carbohydrate inges tion independently improve performance dur ing 1 h of intense exercise. Med Sci Sports Exerc 1995;27(2):200-210. 73. Med Sci Sports Exerc 1992;24:671-678. 74. Coyle EF. Fluid and fuel intake during exercise. J Sports Sci 2004;22:39-55. 75. Jeukendrup A. The new carbohydrate intake rec ommendations. Nestle Nutr Inst Workshop Ser 2013;75:63-71. 76. Jeukendrup AE. Carbohydrate intake dur ing exercise and performance. Nutrition 2004;20(7-8):669-677. 77. Kleiner SM, Greenwood-Robinson M. Power Eat ing Champaign, IL: Human Kinetics; 1998. 78. Welsh RS, Davis JM, Burke JR, Williams HG. Car bohydrates and physical/mental performance dur ing intermittent exercise to fatigue. Med Sci Sports Exerc 2002;34:723-731. 79. Jentjens RL, Shaw C, Birtles T, Waring RH, Hard ingestion of glucose and sucrose during exercise. Metabolism 2005;54(5):610-618. 80. Wallis GA, Rowlands DS, Shaw C, Jentjens RL, of maltodextrins and fructose during exercise. Med Sci Sports Exerc 2005;37(3):426-432. 81. Burgess WA, Davis JM, Bartoli WP, Woods JA. Failure of low dose carbohydrate feeding to at tenuate glucoregulatory hormone responses and improve endurance performance. Int J Sport Nutr 1991;1:338-352. 82. Coggan AR, Coyle EF. Reversal of fatigue during prolonged exercise by carbohydrate infusion or in gestion. J Appl Physiol (1985). 1987;63:2388-2395. 83. Coyle EF, Hagberg JM, Hurley BF, Martin WH, during prolonged strenuous exercise can delay fa tigue. J Appl Physiol 1983;55(1 Pt 1):230-235. 84. Coyle EF, Coggan AR, Hemmert MK, Ivy JL. strenuous exercise when fed carbohydrate. J Appl Physiol (1985). 1986;61(1):165-172. 85. Knipscher BW. Thor3: Humans Are More Impor tant Than Hardware [masters thesis]. Monterey, CA: Naval Postgraduate School; 2010. 86. Nutr Rev 1996;54:S159-S168. 87. lism and endurance performance. J Appl Physiol (1985). 2002;93(3):990-999. 88. M, Thompson M. Mythbusting sports and exercise products. BMJ 2012;345:e4848. 89. balance: a review. J Hum Nutr Diet 2003;16:411-420. 90. uresis during rest and exercise: a meta-analysis. J Sci Med Sport 2015;18(5):569-574. 91. Maughan RJ, Leiper JB. Sodium intake and postexercise rehydration in man. Eur J Appl Physiol 1995;71:311-319. 92. ment of sodium retention hormones during re hydration in humans. J Appl Physiol (1985). 1988;65(1):332-336. 93. Kovacs EM, Schmahl RM, Senden JM, Brouns F. exercise rehydration. Int J Sport Nutr Exerc Metab 2002;12(1):14-23. 94. covery from prolonged, submaximal running and subsequent exercise capacity. J Sports Sci 1998;16:143-152. AUTHORS Capt Zak is with the Stapp Aerospace Medical Facility, Edwards Air Force Base, California. When this article was written, he was a 4th year medical student in rotation Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas. Army Community Hospital, Fort Wainwright, Alaska. Military Medical Center, Joint Base San Antonio-Fort Sam Houston, Texas. HYDRATION STRATEGIES FOR THE FEMALE TACTICAL ATHLETE

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January June 2018 91 ed a parallel hospital system to care for the indigenous nation that denied them adequate access to the Vietnam taneously complicated integration into American hospi unnecessary morbidity and mortality but also severely damaged the morale of these units. Relying on extensive archival records in both the National Archives and col lections at Ft. Bragg that features hundreds of unique interviews, this paper explores how the Special Forces designed, built, and implemented a hospital system to care for these Soldiers. Evolving into surgery-capable locations for American and indigenous medics, treating both battle injuries and endemic diseases. Perhaps most importantly, they raised the morale of thousands of Sol diers by guaranteeing superior medical care. BACKGROUND The Special Forces (SF) were founded in 1952 as a covert War III. 1 burghs, SF A-Teams would, in theory, parachute behind column force. 2 This mission required autonomous medi cal support given the inaccessibility of conventional mil itary medical resources. Accordingly, the Special Forces established an intensive training regimen designed to prepare Army medics to function as autonomous cli nicians. 3 Rigorous, demanding, and with a nearly 50% failure rate, this medical education included classroom lessons and on the job training in local hospitals. 4 In the 1960s, the mission focus of the Special Forces evolved from guerilla warfare to counter-insurgency. after the CIAs debacle at the Bay of Pigs, Kennedy Special Forces. 5 a region by winning the hearts and minds of the local populace. 6 Medicine became especially important to this mission, with counterinsurgency experts envision ing it as powerful tool to appeal to and recruit locals. tended in 1952; rather than just providing trauma care to expected to manage the tropical infections, pediatrics, geriatrics and other sundry diseases associated with any given population. The medic transformed from essen tially a trauma specialist to a family practitioner. Train ing correspondingly expanded and came to include the famous dog lab where students could practice surgery 7 This counter-insurgency focus soon landed the Special Forces in Vietnam. 8 lages that served a mini-basecamps for patrols and for protecting the local civilian population. 9 SF founded as the primary ambassador, ingratiating the SF team into the local village and securing local cooperation and participation. 10 The Special Forces worked to re cruit these locals into a militia to help defend the village, Americas Guerilla Hospitals in the Vietnam War: the CIDG Experience Justin Barr, MD 2017 Spurgeon Neel Annual Award Winner The Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual tradition of the US Army Medical Department. The following essay by Dr Justin Barr was selected as the best submission of the 2017 competition.

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92 http://www.cs.amedd.army.mil/amedd_journal.aspx forming what came to be called Civilian Irregular De nard populations occupying the highlands of Vietnam. MEDICAL PROBLE M S FOR THE CIDG The Montagnard makeup of the CIDG units created im mense medical challenges for the Special Forces. The majority (87%) of the population of Vietnam is Viet ethnic minorities, dubbed Montagnards, or mountain men, by the French, consist of a constellation of small tribes residing in the Annamite Mountains on Viet nams western border. 11 The Montagnards strategic location along the Ho Chi Minh Trail made them valu able allies for whichever side could recruit them, but centuries of discord between the minority people and the Viet Kinh hampered the ability of either the North Vietnamese or South Vietnamese armies to ally with the Montagnards. 12 This same discord undermined medi cal cooperation between the CIDG and the Vietnamese medical system. As the war expanded in breadth and ferocity through the 1960s, CIDG casualties mounted, Preexisting prejudices against the Montagnard people combined with an inadequate health care system for the Vietnamese to create a forbidding medical environ ment. The Montagnard uprising that killed several South 13 all CIDG Soldiers as civilians, thus denying them entry into the military hospital system. 14 Given that in 1963 over 50% of Vietnams physicians wore a uniform and ban areas, the exclusion prevented the men from receiv 15 Furthermore, this change blatantly indicated the governments continuation of its policy of considering Montagnards second-class citi As civilians, the CIDG retained access to provincial hospitals. Hospitals more in name than in reality, the ery 20,000 had a rate of 1/743) 16 provided inadequate care for eth Clayton Peacock found the [Vietnamese] doctors know little more than some of our medics. The surgeons are butchers by and largeI honestly dont think there is a Vietnamese in all Vietnam who really understands what sterile technique is. 17 While undoubtedly hyperbole, any faith in local health care and came to reinforce the perceived necessity of creating a separate system. Special Forces personnel disparaged the poor medi cal care Montagnard received at Vietnamese hospitals. There were instanceswhere the CIDG were taken to the hospital there [South Vietnamese military hospital] and assured they would be taken care of, and the pa tients were found dead in the same place that they had been left three or four days earlier, noted Barry Zindel, an SF physician. 18 Americans regularly recalled anec dotes of Montagnard wounded left in hallways, bereft of food and water, and denied care. 19 This situation created an immense medical problem for the Special Forces. They could not evacuate wounded CIDG to Vietnamese hospitals because of the inad equate care provided. Montagnards, aware of the situ ation, actively refused transfer to local hospitals. 20 SF medics tried to provide as much care as possible in the villages themselves, but they did not have adequate training to treat penetrating wounds to the chest, abdo men, or head, nor did they have the facilities to manage complicated postoperative care. 21 hospitals admitted some of the most desperate CIDG patients, but facilities remained few and far between in the early 1960s and swamped with American casualties, who took priority, by the late-1960s. 22 While frequently ed Montagnard Soldiers from accessing American hos munity could not get the Army to rescind that policy. 23 Wounded Montagnards had nowhere to go. providing them adequate medical support unsettled and frustrated the Special Forces men who lived, and died, alongside the Montagnards. From the ever-important counter-insurgency facet, it hurt the underlying mission. Forces became less aggressive, fearing the consequenc es of getting wounded. Recruitment into the CIDG units medical care for their arms and legs. IM PROVISING A SOLUTION es created and operated local hospitals that eventually evolved into a mini-health care system. It started at Bien Hoa, which provided the model that other regions fol lowed. Captain Richard Hobson II, MC and Captain John Slaughter, MC arrived in Bien Hoa in the fall of 1965 and immediately took notice of the disparity in care. The civilian irregulars were essentially getting very poor medical support, insofar as care that could not be handled at the A-Team, commented Hobson. 24 He SPURGEON NEEL ESSAY AWARD COMPETITION AMERICAS GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE

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January June 2018 93 and Slaughter decided a Civilian Irregular Treatment Center would best remedy the problem. They launched this idea without any material support. assistance, as they wanted to build up the hospital sys tem for the Viet Kinh before attending to the minori ties. 25 to contribute resources, pecuniary or otherwise. Accord ing to Captain James Gay, MC, who later worked in the Bien Hoa Hospital, I do not think enough can be said about the ingenuity and aggressiveness of Dr. Hobson in obtaining permission to attempt to build such a com 26 Slaugh ter and Hobson plowed onwards, improvising, begging, and requisitioning in true-SF fashion. They received a 93rd Evacuation Hospital at Bien Hoa donated operating room equipment, and a spare anesthesia machine came with the compliments of the 3rd Surgical Hospital. The beds in the unit came from the 93rd Evac with the help recalled Hobson. 27 According to SF medic Clarence Page, who assisted in founding the Bien Hoa hospital, We scrounged, we stole, we borrowed, we used out of our supplies, used S-5 supplies, we did everything. 28 29 Because the SF had never managed or even conceived of opening this type of hospital, Medical Service Corps dures from scratch. 30 complicated personnel assignments; the table of orga CIDG Hospital, so they had to second physicians and the primary mission of providing medical personnel to tryside. 31 In 1968, with increased resources dedicated to mally acknowledged the CIDG hospitals, enabling them Families of the patients provided most of the nursing care, including feeding, bathing, and dressing changes. 32 fully functional combat hospital. In December of 1965, constructing the four structures that initially comprised the Bien Hoa CIDG Hospital. These included two fortybed patient wards, a medical supply warehouse (which clinic building. 33 The physical plant soon outstripped themselves just completed internship and were ill-pre pared to treat the complicated combat wounds arriving in triage. SF physicians from the Command Surgeon on down went to extraordinary lengths to cultivate these relation ships. 34 Not that there was any sort of formal agreement between our unit and the hospital, commented Captain Robert Drake, MSC, it was handled primarily on a personal relationship between our physicians. 35 Each CIDG hospital paired with a corresponding American one, and at Bien Hoa that meant the 93rd Evacuation and 3rd Surgical Hospital. 36 Army surgeons took the most complicated cases, including all neurosurgeries, into their own facilities, and used their own equipment and instruments; they then returned the patients to conva lesce in the CIDG hospitals ward. 37 As years passed, the facilities improved and capabilities increased. With the arrival of Captain Eugene Edynak, MC, in 1967, the hospital at Bien Hoa acquired a trained surgeon, which vastly expanded the range of procedures they could perform to include thoracic and abdominal operations. 38 By 1970, the hospital included 160 beds, orate laboratory, powerful x-ray equipment, and sev trained surgeons. By 1968, the demand for beds had out stripped their availability, so the administration splin forty kilometers from Bien Hoa at Long Hai. Here, a SF medic and a few local orderlies took charge of the forty to sixty patients who resided there until they healed or returned for further care. 39 This facility coupled with a prosthetic center that tried to replace amputated limbs and return some semblance of normalcy to the lives of disabled CIDG Soldiers. 40 EX PANSION OF THE CIDG HOSPITAL PROGRA M Paul Ferguson, MC, Captain Brenton Burgoyne, MC, and Captain Homer House, MC, created facilities at Pleiku after spending a couple of months working in the original hospital down south in Bien Hoa. The Pleiku CIDG Hospital collaborated with the local American 71st Evacuation Hospital for complicated cases. 41 They also founded a small, satellite hospital in Ban Me Thuot

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94 http://www.cs.amedd.army.mil/amedd_journal.aspx sickness, and convalescent care. 42 In northern South Vietnam, the Special Forces estab lished a CIDG hospital at Da Nang, where it partnered with American Naval medical facilities. 43 Captain Barry Zindel, the surgeon who founded the SF hospital here, had a unique methodology for acquiring the supplies and services of the Navy Seabees: in return for vasecto mies, Seabees lent their assistance in building the physi cal plant. 44 creativity of the SF medical personnel supporting them. Compared to Bien Hoa and Pleiku, the hospital at Da Nang remained relatively small due to comparatively fewer CIDG camps and excellent cooperation with the Navy. The Mekong Delta region never established a CIDG tion: no Montagnards lived this far south, although the Nungs and Khmer Soldiers faced only slightly less dis crimination. Closer to the capital in Saigon, the area had established a more robust medical infrastructure, and the Vietnamese hospital in Can Tho also did a more acceptable job treating the locals. SF doctors comman deered one of the wards to ensure their forces received equitable and adequate care, but in contrast to the other tive hospital system already in place. The Special Forces preferred to prop up an extant system rather than try to create their own. 45 Established to care for CIDG Soldiers, the CIDG hospi tal saw its patient load come include not only the armed 46 Forces built these hospitals for moral and morale reasons: in doing so, hoped that more combatants would enlist. Since the A-Team medics treated the quotidian cases, or wounded patients, evidenced by the preponderance of battle injuries in the patient load. Between 50% and 70% of CIDG admissions resulted from war wounds, com pared to around 30% of the SF admissions. 47 While the hospitals primarily existed to care for injured CIDG and their families, the institutions also served as ideal locations for practical on the job training, both for indigenous and SF medics. By 1966/1967 when the CIDG hospital program began, many of the SF medics rotating into Vietnam came straight from school in the cation, they lacked practical experience. Spending two weeks in a CIDG hospital at the start of their tour al lowed them to gain this necessary experience before sought some continuing medical education in the mid dle of their tour, either brushing up on skills or increas ing their surgical acumen. 48 Indigenous medics also trained there. Ranging between six to ten weeks, the instruction given to the natives usually augmented that already received in an A-Camp. 49 For both groups, the location served as an ideal school. An extensive and di verse patient population presented a variety of medical experienced paramedical personnel provided a wealth of medical knowledge for the students. By the mid to late 1960s, the CIDG hospital system pro vided extensive care. At its peak, it boasted 420 beds medics and scores of indigenous personnel serving as 50 With nearly 60,000 CIDG Soldiers and their dependents, the did service over 16,000 patients through the course of the war. 51 tional hospitals, they featuring fully-equipped operating and even rehabilitation departments. They provided a level of care otherwise unavailable to the Montagnard these institutions. When one CIDG sergeant with femur fractured from a gunshot wound was mistakenly depos ited in the South Vietnamese army hospital in Saigon and hailed a taxicab so as to receive care at the Bien Hoa CIDG hospital. 52 As important as the medical value was the morale these establishments inspired. Before their existence, Mon sance of Vietnamese doctors; the tribesmen knew they received substandard medical care, and this knowledge tion of the hospitals, the morale went up 300%, ac cording to SF medic John McCray. 53 SPURGEON NEEL ESSAY AWARD COMPETITION AMERICAS GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE

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January June 2018 95 surgical support, is essential to the morale of CIDG in III CTZ. 54 These establishments also improved the SF medics morale; by working there, they took away a well-deserved sense of accomplishment and a skill set unobtainable through their normal training. More im receive good care. responsibility for the CIDG militias, and most A-Teams departed. The CIDG hospitals remained after the last camps shut down, 55 but as the CIDG program soon dis solved under South Vietnamese leadership, the Special Forces decided to close all the hospitals by 12 January 1972. 56 The institutions proved successful in multiple to the Montagnards than previously existed, reducing and Montagnard medics before they deployed into the pect competent, compassionate medical care when sick or injured. Simultaneously improving both health out comes and the counterinsurgency objective of winning the hearts and minds, CIDG Hospitals represented a creative solution to a nuanced problem that ultimately ENDNOTES 1. Alfred H. Paddock, Jr. US Army Special Warfare: Its Origins (Washington DC: National Defense From OSS to Green Berets: the Birth of the Special Forces (No vato: Presidio, 1986). 2. For more on Jedburghs, see: Colin Beavan, Opera tion Jedburgh: D-Day and Americas First Shadow War (New York: Viking, 2006) and Will Irwin, The Jedburghs: The Secret History of the Allied Special Forces, France 1994 II generally, see David W. Hogan, Jr. U.S. Army Special Operations in World War II (Washington DC: Center of Military History, 1992). 3. Louis T. Dorogi, Early Special Forces Medical Training, 1952-1971, Special Warfare 3 (Winter 1990), 28-35. 4. Thomas Bain, Letter to Louis Dorogi, Winter 1977, p. 4, National Archives and Records Administration at College Park (hereafter NARA), Historical Files on SF Medical Activities in the VN War, Record Group 319, Stack Area 270, Row 20, Compartment 06, Shelf 4-6, Box 6, Folder 10 (hereafter shortened to 319/270/20/06/4-6/6/10). Richard L. Coppedge, Interview with Louis Dorogi (22 February 1976) pp. 42-3, John F. Kennedy Special Warfare Center in Aaron Bank Hall at Fort Bragg, North Carolina Box 6, Folder 32. William Posey, Special Forces Medical Training, for Communicative Area Pro Collection, Box 1, Folder 57. Ralph G. Drouin, Let ter to Louis Dorogi, February 1977, p. 1, NARA, 319/270/20/06/4-6/6/6. 5. See especially National Security Action Memo randa numbers 2, 26, 52, 55-56, 110, 114, 124, 131132, 162-163, 182, and 204. These are available from the Papers of the John F. Kennedy, Presi dential Papers Collection, at www.jfklibrary.org/ Historical+Resources/Archives/Reference+Desk/ NSAMs.htm. 6. A Summary of Counter Guerilla Operational Con cepts A Textbook on Guerilla Warfare (Fort Bragg Counter Guerilla Counterinsurgency Operations: A Handbook for the Suppression of Communist Guerilla/Terrorist Operations (Fort Tactics and Techniques in Counter Guerilla Operations (Fort Bragg Counter 7. Coppedge, Interview with Dorogi, 21. Roger A. Juel, Interview with Louis Dorogi (17 December 49. Capabilities of the Special Forces Medical Spe Dorogi Collection, Box 1, Folder 69. Program of Candidate Course (Special Forces), Ft. Bragg, 1 Box 6, Folders 1-3. Ian Sutherland, Special Forces of the United States Army, 1952-1982 (San Jose: R. James Bender Publishing, 1990) 142-143. 8. Francis J. Kelly, Vietnam Series: U.S. Army Special Forces, 1961-1971 (Washington DC: Department of the Army, 1972). Shelby L. Stanton, Green Berets at War: The U.S. Army Special Forces in Southeast Asia 1956-1975 (Novato: Presidio, 1985). 9. Dora Layton, Bonnie Layton Ensor, Charles Lay ton, Interview with Author (20 April 2007) p. 2223. Ronald Shackleton, Village Defense: Initial Special Forces Operations in Vietnam (Arvada, 10. Paul Campbell, Interview with Louis Dorogi (10 lection, Box 6, Folder 28. Campbell, Email to Au thor, 2 March 2007 and 8 March 2007.

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96 http://www.cs.amedd.army.mil/amedd_journal.aspx 11. Montagnard: Tribal Groups of the Republic of South Viet-Nam 1964). 12. For a history of the Ho Chi Minh Trail and Ameri The Blood Road: The Ho Chi Minh Trail and the Viet nam War (New York: John Wiley and Sons, 1999). 13. Kelly, U. S. Army Special Forces, 1961-1971 6364. Stanton Green Berets at War 79-83. Thomas K. Adams, US Special Operation Forces in Action: the Challenge of Unconventional Warfare (Lon don: Cass, 1998) 89. 14. Medical Evacuation and Management of Irregular December 1962) p. 1, NARA, 5th Special Forces Personnel General Records, 472/270/25/2/1/3. See also: William J. Bowen, Interview with Louis Dorogi Collection, Box 6, Folder 24. Jim Cass, In chives, Dorogi Collection, Box 6, Folder 4. 15. Raymond H. Bishop, Medical Support of Stability Folder 30. 16. A Vietnam Case Study, 2. Richard Manson, Let Archives, Dorogi Collection, Box 7, Folder 1. John W. Ferrantello, Area Assessment of Dak To, (1 Banks Physicians (per 1000 people), https://data. worldbank.org/indicator/SH.MED.PHYS.ZS?end= 17. Clayton W. Peacock, Interview with Louis Dorogi gi Collection, Box 6, Folder 15. 18. Barry Zindel, Interview with Louis Dorogi (4 June Box 7, Folder 38. 19. Inclosure [sic] 1 to Annex A to Memo Nr 12, Hq 5th SFG (Abn), 1st Special Forces (26 December 1964) p. 1, NARA, Historical Files on SF Medical Activities in the VN War, 319/631/30/20/2-6/32/5. William Gates, Interview with Louis Dorogi (20 tion, Box 6, Folder 40. James Gay, Letter to Louis lard, Interview with Louis Dorogi (1976) p. 7, AR 20. Peacock, Interview with Dorogi, 46. Richard D. Haskell, Interview with Louis Dorogi (16 April Box 6, Folder 43. 21. Haskell, Interview with Dorogi, 3. Henry Caesar, Interview with Louis Dorogi (18 May 1976) p. 17 22. Spurgeon Neel, Medical Support of the U.S. Army in Vietnam 1965-1970 (Washington DC: Depart ment of the Army, 1973) 1-5. 23. sons Learned for period ending 31 July 1967, (15 lection, Box 4, Folder 66. Demetrious Tsoulos, In terview with Louis Dorogi (25 February 1976) p. Folder 26. 24. Robert W. Hobson III, Interview with Louis Doro Collection, Box 7, Folder 49. Gay, Interview with Dorogi, 5. 25. Morton, ed. Ruben W. Shay (6 November 1963) p. 58, NARA, Historical Files on SF Medical Activi ties in the VN War 319/631/30/20/2-6/12/24. 26. Gay, Interview with Dorogi, 6. 27. Contractors in Saigon had asked for $50,000$70,000. Hobson, Interview with Dorogi, 38-39. not prepared for this type of establishment and did not include complicated medical support items like anesthesia machines, which resulting in some of the scrounging. Robert Drake, Interview with chives, Dorogi Collection, Box 6, Folder 36. Tsou los, Interview with Dorogi, 14-15. 28. Clarence A. Page, Interview with Louis Dorogi (19 lection, Box 7, Folder 53. 29. Craig Llewellyn, Interview with Author (15 May 2007) 16-17. An SF sergeants brother worked on the Saigon docks, and in exchange for alcohol and other gifts, he changed the bill of lading for the ce ment shipment so that it went straight to the CDe tachment at Bien Hoa. 30. SF did have plans and contingencies for a gue rilla hospital deep in denied, enemy territory (see Dwight R. Wade and John Erskine, Medical Sup port of Guerilla Forces, Military Medicine 134, no. 3 (March 1969): 211-214), but they had not devel oped any doctrine for creating a fully functional hospital in friendly (relatively) terrain. For infor mation on the creation of de novo procedures, see Garrett W. Barron, Interview with Louis Dorogi Collection, Box 7, Folder 41. SPURGEON NEEL ESSAY AWARD COMPETITION AMERICAS GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE

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January June 2018 97 31. John J. Bohannon, Interview with Louis Dorogi Collection, Box 7, Folder 42. Stanley Allison, De 1, NARA, 5th SFG (Abn) Headquarters, Assistant 32. Stanley C. Allison, Interview with Louis Dorogi gi Collection, Box 6, Folder 50. Later, a mess hall developed that employed two Vietnamese cooks to prepare meals for patients whose families could not come or who had been killed. Drake, Interview with Dorogi, 13. 33. Hobson, Interview with Dorogi, 17-21. Before the construction of buildings, Hobson and Slaugh ter operated out of a ward in the local provincial hospital. 34. Allison, Interview with Dorogi, 15. 35. Drake, Interview with Dorogi, 46. 36. Gay, Interview with Dorogi, 11. Hobson, Inter view with Dorogi, 27. Page, Interview with Dorogi, 12. Wehland G. Steenken, Interview with Louis Dorogi Collection, Box 7, Folder 22. Tsoulos, Inter view with Dorogi, 7. 37. Elvin R. Hamlin, Interview with Louis Dorogi Dorogi Collection, Box 6, Folder 41. William Frew, Army Medical Services Activities Report (RCS MED-41 (R4)) (1966) p. 29, NARA, Histori cal Files on SF Medical Activities in the VN War, 319/631/30/20/2-6/16/3. 38. residency before arriving in Vietnam; some sub CIDG Hospitals still outsourced their neurosurgery and tried to outsource particularly complicated orthopedic cases to Army hospitals. Gay, Inter view with Dorogi, 38-9. Hobson, Interview with Dorogi, 73. Rodolfo H. Villarreal, Interview with Dorogi Collection, Box 7, Folder 27. 39. The average patient stayed at the convalescent for period ending 31 January 1969 (28 May 1969) p. 87, NARA, Historical Files on SF Medical Ac tivities in the VN War, 319/270/20/06/4-6/3/1. Sean land Bogguess, Hope for the Disabled, Green Beret Magazine IV no. 9 (September 1969): 20-21. Drake, Interview with Dorogi, 6. 40. The newly ambulated soldiers also received physi cal therapy and, when feasible, employment with tion. They (or in case of death, their family) also view with Dorogi, 48-50. Hobson, Interview with Dorogi, 50. CIDG Hospital: Helping your Brother Help Himself Green Beret Magazine V no. 7 (July 1970): 8-9. 41. Interview with Louis Dorogi, (18 December 1976) Box 6, Folder 35. 42. Gary Clark was the sole physician at B-23 for eigh teen months and kept an unpublished diary that de scribes his medical, tactical, and personal experi ences there. A copy of that diary is available in at NARA, Historical Files on SF Medical Activities in the VN War, 319/631/30/20/2-6/30/6. See also: Arthur Steinberg, Interview with Louis Dorogi (19 Collection, Box 7, Folder 23. Tsoulos, Interview with Dorogi, 101. 43. Barry Zindel, Letter to Louis Dorogi, 4 June 1976, 7, Folder 38. Richard Webb, Interview with Louis chives, Dorogi Collection, Box 7, Folder 31. Ron mona, Interview with Author (1 March 2007), 5-6. 44. Llewellyn, Interview with Author, 17. Zindel had undergone a year of urological surgery residency 45. Hobson, Interview with Dorogi, 67. Bohnannon, Interview with Dorogi, 14-20. David G. Tittsworth, Interview with Louis Dorogi (18 May 1976) p. 9, od ending 31 January 1969, 89. Bohannons lack of enthusiasm for the CIDG Hospital concept contrib uted to its reduced stature in IV Corps; Bohannon served as the SF Surgeon at IV Corps for two years. 46. Clark, Diary. Gay, Interview with Dorogi, 40, 42. Tsoulos, Interview with Dorogi, 61. 47. November 1969) p. A-3, A-4, NARA, Histori cal Files on SF Medical Activities in the VN War, 319/270/20/06/4-6/2/9. Monthly Command Sum mary, November 1969 (18 December 1969) p. A-3, NARA, Historical Files on SF Medical Activities in the VN War, 319/270/20/06/4-6/2/10.

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98 http://www.cs.amedd.army.mil/amedd_journal.aspx 48. Robert Fechner, Interview with Louis Dorogi (30 Collection, Box 6, Folder 38. Craig Roberts, Com bat Medic: Vietnam (New York: Pocket Books, 1991) 156. Gay, Interview with Dorogi, 35. Webb, Interview with Dorogi, 37. Tsolous, Army Medi cal Services Activity Report, 15. 49. Gerald W. Foy, Interview with Louis Dorogi (30 tion, Box 6, Folder 39. Hugh R. Hubbard, Interview Report, Lessons Learned for period ending 31 Jan uary 1969, 85. 50. Demetrious Tsoulos, Army Medical Service Activ ities Report, CY 67 (RCS MED 41 (R-4)) (1 Febru ary 1968) p. 5, NARA, Historical Files on SF Medi cal Activities in the VN War, 319/270/20/06/4-6/5/6. 51. Donald Lawrence, Medical History, 5th Special Forces Group (Airborne), p. A4, NARA, 5th SFG (Abn) Headquarters, Surgeon, Command Report ing Files, 472/270/7328/3/1/1. CIDG hospitals aver aged 600-700 admissions each month. 52. Page, Interview with Dorogi, 3. 53. John McCray, Interview with Louis Dorogi (7 No lection, Box 7, Folder 6. 54. (22 December 1968) p.8, NARA, 5th SFG (Abn) 472/270/73/24/5/1/13. See also: CIDG Hospital at Bien Hoa, Green Beret Magazine II no. 1 (January 1967): 18-19. 55. Special Forces Group (Airborne), 28 February 1971) G-2, MHI Archives, MACV Command His torian Collection Preliminary Box Inventory List, Medical Support. 56. Lawrence, Medical History, 5th Special Forces Group (Airborne), A3. AUTHOR versity Medical Center, Durham, North Carolina. SPURGEON NEEL ESSAY AWARD COMPETITION AMERICAS GUERILLA HOSPITALS IN THE VIETNAM WAR: THE CIDG EXPERIENCE

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January June 2018 99 In the fall of 1918, just outside the small French hamlet to as the Red Cross*) nurse Estelle Davis struggled to stay awake. Death and misery surrounded her as she toiled in an American Expeditionary Force (AEF) surgical hospital. Just two years before, three hundred thousand French and German Soldiers had perished at Verdun, only a few miles to her southeast, and now Es telles countrymen entered the fray. Her hospital served the 89th Infantry Division, a unit which had recently un grave wounds while Estelle and her Army counterparts worked feverishly to save as many as possible. The beds remain, and they rarely stayed long either. After surgery, in order to evacuate them to hospitals equipped for long term care. Men with freshly amputated legs hobbled to the nearby train station in order to evacuate further west, away from the front. The hospital carried little in the way of drugs, except for the morphine administered on a regular basis which often did little more than dull the pain of the expectant. Estelle witnessed Army doctors and evacuation hospitals in France during the war, they the brutality of industrial warfare. Estelles very presence was symptomatic of an Army ill prepared for war. Prior to the war, the federal govern ment had designated the Red Cross Nursing Service as thousands of nurses into the Army Nursing Corps from the Red Cross. But some nurses like Estelle remained administratively at leastunder the purview of the Red Cross. When they deployed to France, they were meant to serve in the safety of Paris and other relatively safe areas, working in canteens or convalescence hospitals. Despite this, Estelle found herself working as a civilian women could be in the war. The Army had ordered the tion fell under the militarys commandand in a very focuses primarily on humanitarianism, and maintains a guarded distance from the American military, limiting its interaction to providing support services to service members during family emergencies. 1 However, this was not always the case. Estelles story raises numerous questions about the nature of both the Red Cross and the Army during the early twentieth century. How did it come to be that the Army relied upon the Red Cross for its nursing reserve? How did Red Cross recruitment compare to military recruitment? As the situation at the front deteriorated, the Army called upon the Red Cross to send forth even its civilian nurses. How did these women the complicated relationship between the Red Cross and Ambiguous Duty: Red Cross Nurses and the First World War 2017 Spurgeon Neel Annual Award Runners-up The Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual and MAJ Michael Mobbs (US Army) were selected as runners-up for the 2015 competition. For simplicity, I refer to the American Red Cross as the Red Cross throughout this essay. References to the International Committee of

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100 http://www.cs.amedd.army.mil/amedd_journal.aspx HISTORIOGRAPHY During the First World War, the American Red Cross that the American Red Cross had long been complicit rejected neutrality, it was simply the logical result of a long process. 2 Hutchinsons depiction as reductionist, asserting that the Red Cross nationalistic turn during the war was an aberration, and she focuses on the large amounts during and after the war. Jones dismisses the military reserve function of the Red Cross nursing service as in tions. 3 Although keeping this debate in mind, I largely Red Cross interpreted neutrality during this time period requires in-depth analysis of the Geneva Conventions of 1864 and 1906, and American societyall well be yond the scope of this essay. However, it is important ing Red Cross recruitment material. As the war esca lated and the Red Cross ramped up its nurse recruitment ous ideological boundary between humanitarianism and militarism. But before we look at recruitment, it is im portant to understand how the relationship between the Red Cross and the military was born. CREATING THE RESERVE ing to enlist various state militias into active service. overburdening a weak federal Army bureaucracy. Thou the camps retained few trained medical personnel. The improve conditions in the camps, but that often fell on not have the resources to make any tangible improve ments. 4 The Army Medical Department took these les sons to heart and worked with war department leaders to revise a variety of policies: Army medical authorities received authority to dictate camp sanitation procedures, hospitals. 5 However, the incorporation of nurses did not mean that they would become a regular part of the peacetime Army. War department leaders had little ap petite for excess personnel in the peacetime Army, and nurses would have to be recruited only when necessary. With this new demand for nurses, the Army Medical De partment became yet another thorn in the side for mili institutional changes to the manner in which the Army war Elihu Root with this mission. The militarys newly minted civilian leader determined that the source of the state militias and the federal military. Although states had long resisted federal oversight of their militaries, Root and congressional leaders negotiated with them to reach deals in the Militia Act of 1903 and a subsequent major amendment in 1908. The crux of the new legisla tion stipulated that the federal government would pro vide increased funding to the state militias, while the states would subordinate their militaries to the president in times of war. Before this legislation, states had often balked at orders to leave the borders of the continental of their state. With this new legislation, they submitted States would resist and grumble for many years over they would never regain absolute control of their reserve and militias. 6 It was in this historical moment that congress and the War Department designated the Red Cross as a reserve for the Army Nursing Corps. President Taft signed the legislation into law on April 24, 1912. The laws word ing was relatively vague as to who would be called up and what kind of services they would provide. In fact, the bill referred to anyone called up as civilian employ ees. 7 however, it was understood by the leadership of the main parties involvedthe war department, the Army Nursing Corps, and the Red Crossthat the new pol icy designated Red Cross nurses as a military reserve force. 8 The Red Cross took up this new role with great enthusiasm, as it had in fact been designed by one of its own leaders, Jane A. Delano. Jane Delano graduated from Bellevue Nursing School in 1886, and served with the Red Cross during the Span ish-American War. She loomed large in the American nursing world, serving as the president of the American Nursing Association, and the president of the Board of SPURGEON NEEL ESSAY AWARD COMPETITION AMBIGUOUS DUTY: RED CROSS NURSES AND THE FIRST WORLD WAR

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January June 2018 101 Directors for the American Journal of Nursing. In 1909 called on Delano to serve as the Superintendent of the Army Nurse Corps. 9 Later that same year, the Red Cross created a new division, the Red Cross Nursing Service, and tapped Delano to be its director. Delano now led tary nursing administrations. Delano had long been dis appointed with the inability of the Army to quickly en roll nurses into wartime service. She saw an opportunity to leverage the Red Cross powerful administrative ca pabilities into a nursing reserve. Delano recommended that the Red Cross and the Army create a reserve system with two main components. 10 First, enrollment into the Red Cross nursing service would also mean enrollment as a reservist for the Army Nursing Corps. Second, the Red Cross designated entire hospitals along with their Cross and Army medical leaders designated some hos pitals to fall under Army control and support combat units while others would remain under the Red Cross to perform civilian relief work. 11 The plan for separate hospitals worked better in theory than in practice. As the war developed, many Red Cross hospitals would fall under the de facto command of the Army. A report written after the war explains how the hospitals. The French government restricted where the AEF could set up military hospitals throughout the country. They also required that American military hos As a supposedly civilian institution, the Red Cross had much more leeway when choosing a location to set up its hospitals. The AEF and the Red Cross then set up military hospitals in multiple locations, including one at Beauvais near the Cantigny front. These were Red Cross hospitals in name only, and operated with a full that such methods should be avoided in the future, as a matter of principle. 12 There would be many gaps be tween Red Cross pre-war plans and the realities of op erations during the war. Turning to the nursing recruit ment campaign of 1917, we can see that there was still much ambiguity in the role of the Red Cross during the early days of the war. RECRUIT M ENT As the Red Cross ramped up its nursing recruitment campaign during the early days of the war, it wove to gether a narrative of professionalism, humanitarianism, and militarism. Red Cross leaders were still searching for the American military clear, but still maintained their ideological grounding in humanitarianism. In Au gust 1917, the Red Cross released a bulletin that stated, Germany, the neutrality of the American Red Cross of course ended automatically. 13 In the same breath that they rejected neutrality, the Red Cross acknowledged that they would treat all wounded Soldiers, stating The Red Cross knows no such thing as the nationality of a wounded man. 14 express these ideals in a cohesive recruitment campaign that would convince American women of the 1910s to enroll. saw the rise of an American society based around coer cive volunteerism. At its worst, it silenced, sometimes to the war. 15 in this process at length, but primarily focused on how they functioned in the home front economy as workers. Exploring the Red Cross nursing services recruitment campaign during the early years of the war presents an other angle into the ways in which women were brought Prior to World War I, nurses generally operated within the domestic sphere of American life. Women often worked privately in patients homes for little pay. The American public had only just begun to view nursing as a legitimate profession. 16 In a 1917 recruiting pamphlet, ties that came with Red Cross service. American Red Cross leadership saw the wars potential to grow the profession for the long term. The brochure proclaimed the ability for a Red Cross nurse to earn an assured livelihood and demonstrate her capability as a genuine medical professional. Red Cross leaders envisioned the upcoming war as a potential way to cultivate new lead ers in American nursing, and highlighted the possibili ties for nurses to attain advanced positions of leadership At the same time, the brochure also attempted to rally women with a nationalist message, arguing that it was their duty to join the Red Cross, comparing time in nurs ing school as an honorable duty akin to that of the draft ed men training in Army camps. Alongside this call to humanitarian work that Red Cross nurses would be do ing, such as prenatal care and in-home care for the sick and elderly. Beyond the implications of patriotic obliga tion, the brochure had no details regarding the duties of a Red Cross nurse at war. 17

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102 http://www.cs.amedd.army.mil/amedd_journal.aspx American Red Cross recruitment posters simultaneously recruitment poster stated that the Red Cross serves hu manity Thousand [nurses] By June depicted a Red Cross nurse in the foreground, with a military encampment behind her. 18 this portrayal, the Red Cross was depicted as an exten sion of the military. If the Red Cross served humanity at ment campaigns muddled the nature of service with the Red Cross, they all shared a similar theme of American nurse soothing a wounded American Soldier, while in the backgroundostensibly somewhere far from the nurses locationSoldiers charge across No Mans battle, all the while a nurse sits at a desk ready to enlist women. 19 If soothing the pain of the sick and injured was the Red Cross nurses primary duty, assisting in the pros portance. The posters implied that the nurses would be the wounded safely. As we see from the stories of Estelle and other nurses I discuss later, this would not be the case. The Red Cross advertisement campaign continually rein forced a humanitarian mission that laid within a nation to supporting the American military. Yet still, it did so by stressing the humanitarian work its nurses would do to support the mission, and not necessarily focusing on the employment of nurses near the front. Moving from an interpretive lens, if we turn to the early days of the war we uncover very tangible problems stemming from the relationship between the Army and the Red Cross. BUREAUCRATIC LI M ITATIONS The ambiguous relationship between the Red Cross and the Army created logistical problems from the onset of the war. The Army took no responsibility for provid ing equipment to American nurses during the war, even nal plan crafted by Red Cross and Army leaders prior solely on the Red Cross. Although the policy was no doubt shortsighted, it should also be understood in the context of the era. Prior to the war, there were only a few hundred active nurses. During peacetime, nurses were not considered an organic element of modern militaries, ing to Europe, the Red Cross could not keep up with 20 During the early days of American involvement in the dress, overcoat, cape, and a few varieties of hats. Their winter issue consisted of a single blanket. The uniform issue did not include the white dress they were required to wear, and the nurses had to purchase the required white uniform out of their own pockets. 21 The whites would prove to be ill suited to the muddy conditions of uniform. 22 ply chain (with little help from the Army) and nurses The responsibility fell on Marie B. Rhodes, head of the tance from the English and French chapters of the Red Cross, successfully procuring much needed equipment for nurses all over France. By the spring of 1919, Rhodes nurses in Europe. Aside from uniforms, Army and Red Cross nurses also lacked a general military equipment issue. The allied armies generally issued their Soldiers camp kits, standard layouts that included a cot, blan Nurses received no such issue in the beginning, and had to rely on the generosity of French and British Red Cross supplies. The Army would eventually rectify the nurs ing equipment oversight, but not until December, 1918, a month after the war ended. 23 This equipment shortage was just one of many dilemmas Red Cross Nurses would face as the war developed. As conditions worsened on the front, the Army demanded the service of all spare nursesmilitary or not. DURING THE WAR The Red Cross attempted to retain a division of duties between those nurses that were sworn into the Army, and those that remained with the Red Cross. In March ing a belligerent, the Army Nursing Corps maintained just 403 nurses on active duty, while the Red Cross list ed nearly 8,000 nurses on their rolls. 24 Many of these ducted into the Army Nursing Corps, but the Red Cross also sent hundreds of nurses, like Estelle, who retained tary leaders intended for these women to serve in the rear echelons during the war, far from the front lines. A SPURGEON NEEL ESSAY AWARD COMPETITION AMBIGUOUS DUTY: RED CROSS NURSES AND THE FIRST WORLD WAR

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January June 2018 103 Manual for the Medical Department stated: Except in cases of great emergency, Red Cross person nel serving with the land forces will not be assigned to duty at the front, but will be employed in hospitals in the service of the interior, at the base, on hospital ships and along lines of communications of the military forces of 25 However, as casualties soared and the medical situation in eastern France deteriorated, the plans for a separation ing became so intense that AEF leadership urgently re quested a surge of medical personnel to the front. 26 The Red Cross responded by ordering their nurses in Paris to was sent to the Army hospital at Beauvais. The hospital was poorly equipped, and was little more than an old French schoolhouse with beds. There they worked un der threat of constant German air raids. Fearing that German warplanes might spot the hospital, the hospital commander banned the use of lamps and matches. Dur ing one particularly bad raid, she wrestled to calm men tions. She referred to her service there as being loaned to the military, but in fact she was essentially operating as a military nurse. Without any kind of military train ing, she was working under the command of an Army doctor, subjecting herself to as much danger as any woman in the Army Nursing Corps. Anna Johnson was another such nurse. The Red Cross sent her from Paris to Evacuation Hospital No. 9 at Vau becourt, just outside of Verdun. There, Johnson and other Red Cross nurses worked in dreadful conditions alongside Army medical personnel. They worked in tor rential downpours that would turn the entire base hos pital into what she called a sea of yellow clay mud. Johnson and other nurses at Vaubecourt worked excru save the injured were in vain. Patients streamed into the son had few qualms about working so close to the front lines. She was among many Red Cross nurses that were exceedingly proud to support her countrymen. As the AEF continued to demand more medical personnel near the front, countless Red Cross nurses volunteered for the duty. Like so many men, these women often viewed service near the front as the epitome of patriotic duty. Writing about the situation after the war, Julia Stimson wrote that when the call went out for service near the front, there always were more volunteers than the Red credit should be given [to] the nurses who achieved it, because a hundred were anxious to take her place. 28 FORCED MILITARIZATION Despite Stimsons claim, there were some nurses who tory of the Army Nurse Corps in the Great War sheds some light on the story of these women. Julia Stimson, Superintendent of the Army Nurse Corps wrote the his tory in 1927, wherein she downplayed some of the issues that arose from the convoluted relationship between the Red Cross and the Army. However, in doing so she con depending on your point of view) had forced some nurs es into service with the Army Nurse Corps when these women had been expressly promised that they would remain under the purview of the Red Cross, and would serve in a civilian capacity. Prior to American involve ment in the war, many of these women adamantly ex pressed that they had no desire to serve in the military. The Red Cross leadership soothed their fears that no such change in status would occur. In her book, Stimson acknowledged the forced enlistment, but explains that were unaware of any such previous agreements with the ed such extreme measures, explaining: the institution of this policy on the part of the Red Cross in Washington, but even if it had been known it is not probable that any other action could have been taken than that which was taken when these nurses were called from their civilian work and placed upon active duty with the Army. 29 A memo written to Stimson just a month after the ar mistice further expands upon the issue of forced enlist ments. Clara Noyes, the Director of the Field Nursing Service Bureau, lamented that she and her aides had personally assured a great number of women that they would not be enlisted into the Army. She wrote: There was no nurse who left this country who did not have a formal communication from me saying that it was der the Red Cross and that transfer to the Army would not be permitted. 30 Noyes did not feel particularly sympathetic to those women who did not wish to serve in the Army, calling

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104 http://www.cs.amedd.army.mil/amedd_journal.aspx them unpatriotic later on in the same letter. She and other Red Cross and Army leaders believed that the cir cumstances of the war in 1918 necessitated the measures taken, but still lamented that they had broken trust with so many women. The problem of forced enlistments continued to fester after the armistice. Women enlisted into Army Nurse Corps, including those who had never wished to serve in the military, remained in the Army for some time. This only exacerbated the moral conundrum for the nurses that had never intended to be a part of the military. They had joined the Red Cross with the promise of humani tarian work, and now found themselves still languishing in the AEF, months after hostilities had ended. Some Red Cross, and destroying the concept of neutrality on 31 The crisis did not last too long however, as over the following few Army released most nurses from service. Those nurses who wished to remain in active service could apply di rectly to the superintendent of the Army Nurse Corps. However, either due to lack of interest, or more likely bureaucratic impediments, only forty-eight nurses had gone through this process by mid 1919. 32 CONCLUSION Problems stemming from the complicated relationship between the Red Cross and the Army continued to ap pear long after the armistice. Red Cross and Army Nurs ing Corps leaders lobbied successfully for Army nurses to receive rank in 1920, and then again for equal retire retirement only applied to active nurses and not those who had entered the Army Nursing Corps as reserve nurses through the Red Cross, even if they had contin Edith Thorsen, attempted to retire from active duty in 1930 but was denied retirement by the Army comptroller on the basis that she was not eligible for retirement as a reserve nurse. The case made its way to federal court in 1934 where the judges eventually decided unanimously in Ediths favor. 33 Still, she had trudged through a legal battle over four years, spending precious time and mon laws interpretation. The fact that Edith had entered the Army through the Red Cross labelled her as a reserve nurse for the entirety of her career. Jane Delanos plan had certainly succeeded in supplying nurses in a time of the war ended. leadership struggled to balance its role as a civilian hu as a de facto wing of the American military. The re cruitment campaign in 1917 and 1918 laced principles of militarism and humanitarianism in a way that found widespread appeal among American nurses. Those like Estelle Davis joined the Red Cross out of a deep-seated sense of patriotism. In an interview in 1982, she said that she could not think of not being with my coun try at a time like that. 34 Like many other nurses, Es service with the Red Cross. She understood the Red depicted them: service with the military was humani tarianism. Yet still there were others who felt that the the Red Cross had promised no such thing would hap essay tries to recover both the stories of nurses like Es telle and also those Red Cross nurses that believed in a protestors, 35 these particular nurses have unfortunately been silenced by the historical record. 36 In her book Doughboys, the Great War, and the Remak ing of America, Jennifer Keene argues that the integra both the Army bureaucracy and American society after the war. Keene points out that despite the coercive pow 37 In the same light, civilian Red Cross nurses represented a critical el Army nurses cemented the place of nurses as a perma nent asset within the Armys medical establishment. ACKNOWLEDGE M ENT of interest. ENDNOTES 1. American Red Cross, Missions & Values, Ameri can Red Cross Website, http://www.redcross.org/ about-us/who-we-are/mission-and-values (accessed August 30, 2017). SPURGEON NEEL ESSAY AWARD COMPETITION AMBIGUOUS DUTY: RED CROSS NURSES AND THE FIRST WORLD WAR

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January June 2018 105 2. John Hutchinson, Champions of Charity: War and the Rise of the Red Cross Adobe Digital ed. (Boul der: Westview Press, 1996), 735-736. 3. Marian Moser Jones, The American Red Cross from Clara Barton to the New Deal (Baltimore: 4. Allan R. Millet, Peter Maslowski, and William B. Feis, For the Common Defense: A Military History of the United States from 1607 to 2012 (New York: Free Press, 2012), 269-270. 5. Graham A. Cosmas, An Army for Empire: The United States Army in the Spanish-American War 1998), 302-304. 6. Jerry Cooper, The Rise of the National Guard: The Evolution of the American Militia versity of Nebraska Press, 1997), 108-109. 7. An Act To provide for the use of the American Na tional Red Cross in aid of the land and naval forces in time of actual or threatened war Public Law 132, 66th Cong., 2nd sess. (April 24, 1912). 8. Jane A. Delano, The Red Cross, The American Journal of Nursing 11, no. 11 (July 1911): 807. 9. Mary T. Sarnecky, A History of the U.S. Army Nurse Corps (Philadelphia: University of Pennsyl vania Press, 1999), 69-74. 10. Foster Rhea Dulles, the Red Cross: A History (the Red Cross, 1950), 96. 11. Sarnecky, 80-81. 12. American Red Cross Military Hospitals 1919, RG 112, Box 8, Folder Correspon dence between Miss Carrie Hall and Miss Stimson re A.E.F Nurses, etc., NARA, Washington D.C. 13. The American Red Cross, The Red Cross Bulle tin (Bureau of Publications for the Department of Chapters, August 17, 1917), 3. 14. Ibid., 3. 15. Uncle Sam Wants You: World War I and the Making of the Modern Ameri can Citizen 2008), 18-19. 16. Kay Hawes, World War I and its Impact on the Nursing Profession, http://www.kumc.edu/newslisting-page/lworld-war-and-its-impact-on-thenursingprofession.html, (February 3, 2016). 17. American Red Cross Recruitment Pamphlet, Nurs ing: A National Service in This Time of Stress [ca. 1917], digitalcollections.archives.nysed.gov/index. php/nysa/ Download/Full/occurrence_id/126 (ac cessed August 30, 2017). 18. American Red Cross, Five Thousand by June, Li brary of Congress Web site, https://www.loc.gov/ resource/cph.3g07782/ (accessed August 30, 2017). 19. American Red Cross, If I Fail He Dies: Work For the Red Cross, https://www.loc.gov/item/00651856/. Accessed August 30, 2017. 20. Julia C. Stimson, History of Nursing Activities, A.E.F. on the Western Front During War Period May 8, 1917-May 31, 1919, RG 112, Box 8, Fold er History Nursing Activities A.E.F. (Stimson), NARA, Washington D.C. 21. Julia C. Stimson, Summary of the History of the Nursing Service of the A.E.F. February 26, 1920, RG 112, Box 8, Folder History Nursing Activities A.E.F. (Stimson), NARA, Washington D.C. 22. Stimson, History of Nursing Activities, A.E.F. on the Western Front During War Period May 8, 1917May 31, 1919. 23. Stimson, Summary of the History of the Nursing Service of the A.E.F. 24. Ibid., 99. 25. Manual for the Medical De partment United States Army, Corrected edition, (Washington: Government Printing Press, 1918), 179. 26. Stimson, History of Nursing Activities, A.E.F. on the Western Front During War Period May 8, 1917May 31, 1919. 27. Lavinia L. Dock et al, 648. 28. Stimson, Summary of the History of the Nursing Service of the A.E.F. 29. Stimson, The Medical Department of the United States Army in the World War Part two (Washing 327. 30. Clara D. Noyes to Julia C. Stimson, December 21, 1918, RG 112, Box 8, Folder Correspondence be tween Miss Carrie Hall and Miss Stimson re A.E.F. Nurses, etc., NARA, Washington D.C. 31. Ibid. 32. Sarnecky, 135. 33. (Federal Court of Claims, 1934). 34. Davis. 35. For analysis of resistance to the war and the draft, For Peace and Justice: Paci see Press, 1971). 36. Sarnecky, 173-174. 37. Jennifer D. Keene, Doughboys, the Great War, and the Remaking of America (Baltimore, The Johns AUTHOR :KHQ\003WKLV\003HVVD\\000ZDV\003ZULWWHQ\017\003&\003$O\277Q\003ZDV\003D\003JUDGX Wisconsin.

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106 http://www.cs.amedd.army.mil/amedd_journal.aspx The experience set forth herein is largely that of the World Wars. Weapons and methods of warfare have changed since that time and such changes have always American Civil War would have proved to be largely un reliable in 1917-1918; and it may well be that the experi ence of the World Wars will prove to be equally unreli able in future wars. But, even if such an experience is of no greater value than to serve as the basis of an educated guess, it is still better than no experience at all 1 To engage in war is to engage with risk. From the Amer ican Revolution onward, American military leaders For most of the 18th and 19th centuries, American mili man and material resources against an opponentbe lieved risk was seated in the unknowable and unpredict rates as the happy consequence of a sound military plan. However, around the start of the 20th century, there arose within the American military medical community a perception that casualty rates represented a risk that could be predicted and controlled. This shift in percep tion was predicated on two events: the vast amounts of casualty statistics that only entered the printed record following the American Civil War, and the invention of tabulating and sorting machines that could reveal the patterns within this data. Within the recorded statis existed a mathematical logic that could be deciphered to quantify risk in future engagements. Reduced casu alty rates, then, were not a consequence but the actual goal of proper medical planning based in a mathemati cal approach to controlling risk. Spurred by the Ameri can experience during World War I, these events led to the publication of Field Manual 8-55 Medical Field Manual Armys institutional experience with casualties in war, Army. 2 The collection of casualty data following the Civil War became the foundation of Army medical planning in the beginning of the 20th century and represented a deliber ate choice to represent casualties as a martial risk that could be understood and, perhaps, controlled. Military battle, they had to predict the number of battle casualties in advance. This was a problem that military thinkers on both sides of the Atlantic examined closely as Europe, and shortly thereafter, America entered into an unprec edented world war. 3 Americas entry in to World War I heralded a massive inadequacies of military medical planning and casualty prediction. By November 11, 1918, America sent over 2,000,000 service members to the European continent, 4 It soon became the opinion of World War I medical plan ners that the experiences of the American Civil War, were of little value. 5 and trench warfare represented new risks which ren dered past experience completely obsolete in the eyes of the Army medical community. While military medi equipment and personnel necessary for proper medical care without a relevant planning method proved prob lematic. 6 As a result, casualty predictions were sporad ic and inaccurate, and the medical planning based on these predictions were wholly inadequate. The Meusequences of inadequate casualty prediction and medical planning. Though military commanders understood the importance of providing adequate medical care, they knew that transportation was so urgently needed for many other things that they did not feel that it should be provided for unnecessary hospital equipment or personnel. 7 Because there was no suitable method of predicting battle casualties, only 18,000 hospital beds were planned to support an American force of 600,000. 8 SPURGEON NEEL ESSAY AWARD COMPETITION The Figures of Experience: A Brief History of Risk and Planning Within the Army Medical Community

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January June 2018 107 few days alone, requiring the evacuation of over 10,000 Soldiers, delaying lifesaving surgery and increasing morbidity and mortality rates. 9 The failure of military medical planners to predict casualties in advance of a tens of thousands of service members. The military medical community knew it had to do bet ter. This task fell to the Armys Medical Statistics Sec assigned to the Medical Records section of the Surgeon 10 This po Love would later write, this experience gave him the unusual opportunity to become indoctrinated with the vice so that it could better preserve the health of the Army. 11 Love had a passion for medical statistics and for serving the Armys medical needs, traits that would set him apart in the eyes of his superiors. Loves assign ment paved the way for his return to the Surgeon Gen assumed charge of the Medical Records Section, Divi sion of Sanitation. 12 Major General William Gorgas, then Surgeon General the Armys medical service in World War I highlighted the need to upgrade the Medical Departments record keeping and revisit the use of statistics to aid medi cal planning. Gorgas charged Love with overhauling the Medical Records Section and updating the records keeping process. As head of the Medical Records Sec tion, and later as chief of the Medical Statistical Divi sion, Love oversaw the collection and analysis of all the Armys medical statistics. Not only was Love respon sible for the statistical tabulation of casualty data from the front, his department also worked with the Provost lective Service registrants. 13 process 1,500 cards a day, and by the end of the war, Loves section had processed the statistics of over 2.5 million records. 14 From 1921 until 1927, the Statistical Division under Loves leadership compiled over 2,000 pages of data, representing the complete statistical re cord of the anthropological, medical, and casualty data chine and statistical analysis, Love generated mathemat predictive model for hospital admission and discharge rates; a model predicting discharged patients that could return to battle; and a model that could predict combat casualties prior to an engagement. Titled War Casualties: Their Relation to Medical Ser vice and Replacements, Loves study was published in The Army Medical Bulletin Number 24 in 1931. Writing in the Forward, Colonel C. R. Reynolds, com mandant of the Medical Service Field School, noted that Loves study furnished the soundest basis for war plan These data must be subjected to careful analysis, tak ing into consideration all evident and conceivable factors ence thus obtained, and comparing the past with present and future conditions, must be based our estimates of the losses to be expected and of medical service require ments in future military operations. 15 Reynolds continued, writing that Loves study was valuable in determining more accurately than by pre given situation [and] will also be of value in studies relating to personnel procurement and replacement. 16 Love also expressed lofty goals for his study, presenting what he described as a system for estimating, on the ba sis of our casualty experience in past wars, the require evacuation of front line casualties. 17 Love presented his system in a simple table that provided a summary of the daily casualty ratesto be used as a basis for estimating the requirement for medical personnel and equipment 18 The data in this table gave a method for estimating the medical needs prior to an engagement while also es timating likely replacement needs. 19 For example, an infantry regiment comprising 1,000 Soldiers engaged in severe combat could expect a battle casualty rate World War I, attempting to predict casualties for units in combat, fell victim to their inability to predict ca care. Loves method appeared to mitigate this risk, as amount of personnel, supplies, litters, hospital beds, etc, on hand prior to an engagement. It appeared that Love by Army planners in France a decade prior. As early as 1936, it seemed clear to senior military lead ers that another war was near at hand, and Loves model was considered an important contribution to military

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108 http://www.cs.amedd.army.mil/amedd_journal.aspx 20 By 1941, mere months before the attack on Pearl Harbor, the Army instituted Loves method as doctrine, the funda mental principles by which the military forces or ele ments thereof guide their actions in support of national objectives. 21 Published on March 5, 1941, as FM 8-55, Medical Field Manual, Reference Data Loves mod el became not merely a suggestion, but the institutional ly sanctioned method for conducting objective military medical planning. As FM 8-55 acknowledged, even if the planning method was of no greater value than to serve as the basis of an educated guess, it [was] still bet ter than no experience at all. 22 This educated guess was all the Army had as World War II progressed and the Allies turned their eyes to the shores of Normandy and began planning the largest amphibious operation in military history. the cross-Channel invasion agreed that they needed a common basis for estimating casualties, but were ham of the Allied assault force was not yet known, nor was there previous experience with amphibious assaults of the scale proposed. 23 ic predictions, virtually meaningless absent the invasion plan itself: 2% casualties in the embarkation area, 25% casualties during the assault itself, 10% casualties per 24 the casualty estimation standards outlined in Army Medical Bulletin No. 24 and FM 8-55 25 Comment ing on these documents in June of 1942, Colonel Paul R. ain in the fall of 1941, where he remained throughout the invasion planning) wrote that insofar as battle casual ties are concerned, these data are the most comprehen sive in the world. The experience of [World War II] may indicate the necessity of revising these tables; but, until low this experience closely. 26 SAC), called for three assault divisions and four de 27 Morgans plan called for an invasion force of roughly 78,000 Soldiers, and this resources, especially landing craft. 28 In fact, when Mor gan presented his plan to the Combined Chiefs in July 1943, he advised that in proportion as additional ship ping, landing craft, and transport aircraft can be made available, so the chances of success in the operation will be increased. 29 Although the primary consideration for of the invasion force, it also hinged on the casualty fore suitable ships and/or crafts are earmarked and adapted where necessary for [the evacuation of wounded], ade quate provisions for medical evacuation will not be pos sible. 30 at present exists for the evacuation of wounded during the assault, the casualty estimate forecasted a total of 31 by British planners the previous year. In fact, the chief named Lieutenant Colonel G. M. Denning, and his small informal section also included a Royal Navy medical method of casualty estimation to Morgans original in vasion plan. 32 While these initial numbers derive from the British SPURGEON NEEL ESSAY AWARD COMPETITION THE FIGURES OF EXPERIENCE: A BRIEF HISTORY OF RISK AND PLANNING WITHIN THE ARMY MEDICAL COMMUNITY Figure 1 Love presented a full explanation of where he drew his data and how he applied statistical analysis. This table represented casualty rates per 100(%) of unit strength suggested as a basis for estimating the necessary medical relief on severe combat days, as determined by the American Expeditionary Forces experience.

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January June 2018 109 American doctrine for casualty estimation became the favored method as early as mid-August of 1943. A table 33 Written in pencil at the top of the casualty table a plan ner noted that the data was derived using Gen Loves Scheme of Estimation of Casualties. 34 In addition to the Thomas J. Hartford also advised the medical support 35 Hartford was on loan from the medical section of the American command struc ture set up to oversee American forces in Britain, and would have been aware of FM 8-55 and Army Medical Bulletin No. 24 36 Whether or not Hartford had direct an unsigned memo dated September 25, 1943 and pro method for estimating casualties. 37 The memo stated that given that the battle casualty rate will depend upon involved and the type and severity of the action antici pated, a new method would be used to determine the severity of losses. 38 This new method, adopted merely two months after Morgan submitted his report, mirrored that process outlined in FM 8-55 (Figure 2). 39 fy Morgans request for additional transportation craft. As a result, in order to meet the demands of the crossChannel invasion, American war production increased its output of landing craft by 25% at the direction of the 40 critical item of equipment for the world-wide strategical program. Every operation contemplated [was] a landing was in competition for this scarce resource. 41 A com parison of expected casualties to available evacuation craft illustrated the point of these urgent requests for more landing vessels. An April 1944 study showed that Meanwhile, the second wave of landing craft, scheduled to arrive within hours on the next tide, was supposed to evacuate these casualties after depositing fresh troops. The only problem was that after the second wave land could only evacuate a total of 1,950, leaving an excess of 2,650 casualties on the beach. The study showed that this excess of wounded would continue to compound from D Day through D+14, when the number of avail catch up with demand. 42 Though casualty estimates drove much of the discus these estimates reached well beyond landing craft alone. SHAEF planners used the casualty estimates to request hundreds of thousands of hospital beds, tens of thou hospital trains capable of transporting thousands of ca sualties at a time throughout Britain. 43 Medical supplies included hundreds of blankets, a hundred liters of blood, splint sets, cases of dressings, and boxes of plasma for every landing craft. 44 Military litters were converted to to support the invasion and the expected number of ca sualties. 45 Meanwhile, commanders used the casualty estimates to plan for replacements needed to keep the invasion moving forward. 46 Figure 2 Comparing the rates listed in this table to the rates listed in FM 8 55 make it clear that COSSAC planners adopted the American doctrine of casualty estimation. There are only minor points of variation between the above table and that printed in FM 8 55 For example, the Light battle day column above is a direct copy of the Average for all days in line column listed in FM 8 55 While FM 8 55 lists a range for Severe battle day (ie, 12 15 6 8 2 3 and 7 1 5 ) the table above adopts the high end of these ranges. Finally, FM 8 55 lists 35 % for Brigades and 12 % for Divisions on Maximum battle days. There is no accounting for the adjustments made in the table above, but while the reader may conclude the adjust ment to 25 that the British method applied a 25 % casualty rate to all types of formations, without variation.

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110 http://www.cs.amedd.army.mil/amedd_journal.aspx In the aftermath of the invasion, Loves casualty predic tion model proved less than accurate. While the realities generally place Allied casualties closer to 10,000far less than the number predicted by Loves model. Nev ertheless, after World War II, FM 8-55 was updated to include new elements of warfare that were not present in the World War I data Love used. 47 Statistics from ar mored, amphibious, and airborne operations, as well as casualty data from the Korean and Vietnam wars were incorporated into future planning manuals. 48 These up dated manuals stated that Loves method was designed for rough, quick estimates only and not as a substitute tions and conditions of a particular operation plan. 49 The updated publications advise planners that experi ence clearly indicates that the estimation of probable casualty rates in advance is not a simple matter that can be reduced to a general formula, while providing up dated formulas based on Loves original work. 50 Nearly Army medical planning lives on. ENDNOTES 1. Field Manual 8--55 Medical Field Manual Refer ence Data 2. nition of casualties: Any person who is lost to the status whereabouts unknown, missing, ill, or injured (JP 1-02, 2010). Medical planning, espe cially by World War II, attempted to predict not only casualties resulting from battle, but also rates of sickness and disease. The word casualties was ubiquitous and did not always make a distinction between casualties occurred in direct combat with an opposing force versus casualties caused by ill ness or accidents. As much as possible I will try to to killed, wounded, or missing as a direct result of general term casualty to refer to military service members who become sick, or otherwise sustain an injury or are killed by causes not related to direct combat with an enemy force. 3. Invasions of Japan, 1945-1946: Planning and Policy Implications, The Journal of Military History 61, no. 3 (1997): 527. As Giangreco points out, as does develop a casualty prediction model in America), much of the methodology applied to the statistics their examination of battle casualties in the FrancoPrussian War. In general, there was a fascination to state that the structure of the American Expe ditionary Force in Word War I was based on the Prussian model. 4. Marvin A. Kreidberg and Merton G. Henry, His tory of Military Mobilization in the United States Army: 1775-1945 (Washington, DC: Department of the Army, 1955), 336. 5. Love, Albert Gallatin, Eugene L. Hamilton, and Ida Levin Hellman, Tabulating Equipment and 6. Sanders Marble, How Many Hospitals to Deploy?, The AMEDD Historian 17 (2017): 3. 7. Love, et al, 87. 8. Marble, 3. 9. Ibid. 10. Rohlader, Esther E., A Concise Biography of Brig adier General Albert Gallatin Love, M.C ., (Wash ington, D.C.: General Reference and research Section, Walter Reed Army Medical Center, 1964), 1-8. 11. Love, et al, 31. 12. Rohlader. 13. Ibid., 73. There is a separate history behind Loves vost Marshall intended that the data analysis aid future wars by providing estimates for uniforms, equipment, etc., based on the measurements of the average draftee. Additionally, this data was used to gather eugenics data on draftees and much of the data published by Love and the Medical Statistics Division presents data on race, geography, health, etc. 14. Ibid., 64 and 74. 15. Love, v. 16. Ibid. 17. Ibid., vii. 18. Ibid., 122. 19. Included in Loves monograph was a lengthy dis cussion of what percentage of casualties who would return to the front based on their wound or injury. This information is not presented in the table above, but medical planners would account for this as they allocated medical supplies and personnel into their SPURGEON NEEL ESSAY AWARD COMPETITION THE FIGURES OF EXPERIENCE: A BRIEF HISTORY OF RISK AND PLANNING WITHIN THE ARMY MEDICAL COMMUNITY

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January June 2018 111 plan. For example, of the 12.6% expected wounded in an infantry regiment, some percentage of that would quickly recover and be discharged from a care facility and be returned to the front. 20. Patton, George, letter to George C. Marshall, 26 August 1936, private collection of Ellene Winn, Marshalls promotion to brigadier general, Patton wrote that as things look now we seem to be about to have some sort of a new war, dont [sic] forget me if we do. At the time Patton was a lieutenant colonel assigned to a military intelligence unit in Hawaii. 21. Joint Publication 1-02 Dictionary of Military and 22. Field Manual 8-55, 46. 23. Sanford V. Larkey, Administrative and Logistical History of the Medical Service Communication Group 498, Entry 54a, Stack Area 290, Row 57, Compartment 18, Shelf 4, Box 164 (College Park, 24. Ibid., 60. 25. geon General, Department of the Army, 1963), 305. 26. Medical Services SubCommittee, June 14, 1942. Row 17, Compartment 5, Shelf 2, Box 309 (Col States), 1. 27. pendices, July 30, 1943, File: Committee Report Library, Walter Bedell Smith Papers). 28. Ibid., 85. 29. Ibid., ii. 30. Ibid., 106. 31. Ibid. 32. Graham A. Cosmas and Albert E. Cowdrey, The Medical Department: Medical Services in the Eu in World War II: The Technical Services) (Wash ington D.C.: Center of Military History), 153. From the primary historical record available to me at this what methodology was used to forecast casualties when Morgan presented his plan to the Combined sion by comparing the number of casualties Mor gan presented (19,500) against the proposed assault force (~78,000). The resulting percentage is 25%. It using Loves method, then the appropriate planning factor for Division casualties would have been 15%. Thus, I conclude the 25% method was a carryover 33. Air Force) August 12, 1943, Evelyn A Sutton Pa pers. The Museum of Military Medicine Archives. 34. Ibid. 35. Cosmas and Cowdrey, 153. 36. Ibid. 37. Estimate of Casualties, September 25, 1943, En try 1, Evelyn A Sutton Papers, The Museum of Military Medicine Archives, Keogh Barracks, force behind the revision in planning method. From the record it is clear that the method of estimating casualties changed between July and August of 1943, and that the subsequent casualty prediction changed as well. The record also makes explicitly clear that the method used to forecast casualties was the method outlined by Love. As Hartford was of this change. 38. Ibid. 39. Ibid., 1a. 40. 1943, Record Group 331, Entry 3, Box 122 (College 41. Conference, and this quote was among the items Conference. 42. Table Estimated Casualties, April 8, 1944, File SHAEF 370-05 MED, Record Group 331, Entry 65, Stack Area 290, Row 7, Compartment 34, Shelf 4, Box 3 (College Park, M.D.: National Archives of 43. Conference with General Hawley, April 18, 1951, Page 4, File HD 000.71 Interviews Shoock-Beas son Welch, Record Group 112, Entry 1013 (Center

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112 http://www.cs.amedd.army.mil/amedd_journal.aspx 18, Compartment 19, Shelf 02, Box 1 (College Park, Row 17, Compartment 5, Shelf 3, Box 311 (College and Page 13 Reception and Distribution of Casu A, May 25, 1944, File Evacuation, Record Group partment 5, Shelf 3, Box 312 (College Park, M.D.: 44. Initial Evacuation of Casualties from Far to Near Shore: Army/Navy Responsibilities, May 19, 17, Compartment 5, Shelf 3, Box 311 (College Park, 45. F. J. Horne, LSTs Special Fittings for Casualty Area 390, Row 17, Compartment 4, Shelf 6, Box 282 (College Park, M.D.: National Archives of the 46. Air Force) August 12, 1943, Evelyn A Sutton Pa pers. The Museum of Military Medicine Archives. 47. Giangreco, 528. 48. Ibid., 529. 49. Manual, Organizational, Technical, Data Plan ning Factors (Volume 2) (Washington, D.C: Head quarters, Department of the Army, 1987), 4-7. See cal and campaign planners built their casualty es timates as best they could using tables constructed when factored with projected troop strength, op erational plans, and intelligence estimates of Japa the invasion of the Philippines, planners at various echelons in MacArthurs headquarters were able to ures with data compiled from the hard-won battles on and around New Guinea. Giancrego does not provide any reference or analysis to back up this claim, but the idea of incremental updates based on timely data is an accepted fundamental of sound forecasting. If Giangreco is correct, it would seem inexcusable that planners in the European Theater did not do the same thing because they too, like cess to all the casualty experience of the British. 50. Ibid., 5-1. AUTHOR most recently as a troop and company commander in 1st Brigade, 82nd Airborne Division, Fort Bragg, NC. He instructor, teaching a course in American History. SPURGEON NEEL ESSAY AWARD COMPETITION THE FIGURES OF EXPERIENCE: A BRIEF HISTORY OF RISK AND PLANNING WITHIN THE ARMY MEDICAL COMMUNITY

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The United States Army Medical Department Journal is published quarterly to expand knowledge of domestic and international military medical issues and technological advances; promote collaborative partnerships among the Services, components, Corps, and specialties; convey clinical and health service support information; and provide a professional, high quality, peer reviewed print medium to encourage dialogue concerning health care issues and initiatives. All manuscripts will be reviewed by the AMEDD Journal s Editorial Review Board and, if required, forwarded to the appropriate subject matter expert for further review and assessment. 1. Related to individual authors commitments: tionships that might bias the work or information presented in the manuscript. To prevent ambiguity, authors must state explicitly on the title page, providing additional detail, if necessary, in a cover letter that accompanies the manuscript. 2. Assistance: Authors should identify Individuals who provide writing or other assistance and disclose the funding source for this assistance, if any. 3. Investigators: in the manuscript. 4. Related to project support: Authors should describe the role of the study sponsor, if any, in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication. If the supporting source had no such involvement, the authors should so state. When reporting experiments on human subjects, authors must indicate whether the procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. If doubt exists whether the research was conducted in accordance with the Helsinki Declaration, the authors must explain the rationale for their approach and demonstrate that the institutional review body explicitly approved the doubtful aspects of the study. When reporting experiments on animals, authors should indicate whether the institutional and national guide for the care and use of laboratory animals was followed. Identifying information, including names, initials, or hospital numbers, should not be published in written descriptions, photographs, as well as in print after publication. Patient consent should be written and archived, either with the Journal the authors, or both, as dictated by local regulations or laws. 1. Manuscripts may be submitted either via email (preferred) or by regular mail. Mail submissions should be in digital format (prefer ably an MS Word document on CD/DVD) with one printed copy of the manuscript. Ideally, a manuscript should be no longer than 24 double-spaced pages. However, exceptions will always be considered on a case-by-case basis. 2. The American Medical Association Manual of Style governs formatting in the preparation of text and references. All articles should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. Inclu sion of a list of article acronyms and abbreviations can be very helpful in the review process and is strongly encouraged. 3. A complete list of references cited in the article must be provided with the manuscript, with the following required data: Reference citations of published articles must include the authors surnames and initials, article title, publication title, year of publication, volume, and page numbers. Reference citations of books must include the authors surnames and initials, book title, volume and/or edition if appropriate, Reference citations for presentations, unpublished papers, conferences, symposia, etc, must include as much identifying information as possible (location, dates, presenters, sponsors, titles). 4. Either color or black and white imagery may be submitted with the manuscript. Color produces the best print reproduction quality, but please avoid excessive use of multiple colors and shading. Digital graphic formats (JPG, TIFF, GIF) are preferred. Editable versions with data sets of any Excel charts and graphs must be included. Charts/graphs embedded in MS Word cannot be used. Prints of photographs are acceptable. If at all possible, please do not send photos embedded in PowerPoint or MS Word. photographic print on the back. Tape captions to the back of photos or submit them on a separate sheet. Ensure captions and photos are indexed to each other. Clearly indicate the desired position of each photo within the manuscript. 5. information must be included on the title page of the manuscript. Submit manuscripts to: DSN 471-6301 Comm 210-221-6301 Email: usarmy.jbsa.medcom-ameddcs.list.amedd-journal@mail.mil

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