Force Health Protection Research Articles

Distribution and larval habitats of Anopheles species in northern Gyeonggi Province, Republic of Korea

A total of 180 larval collection sites (e.g., rice paddies, marshes, ground pools, ponds, stream margins, and irrigation and drainage ditches) was surveyed within a 2 km radius from Warrior Base training area, 5 km south of Panmunjeom (Joint Security Area, demilitarized zone), Gyeonggi Province, Republic of Korea (ROK), from May through October, 2007 to characterize larval habitat distributions of members of the Anopheles Hyrcanus Group (An. sinensis, An. lesteri, An. pullus, An. belenrae, An. kleini, and An. sineroides). A total of 5,859 anopheline larvae was collected from 84.4% of the sites surveyed, of which 4,071 were identified to species by polymerase chain reaction (PCR) using the ribosomal DNA internal transcribed spacer 2 (rDNA ITS2). Anopheles sinensis (52.6%) was the most frequently collected, followed by An. kleini (29.4%), An. sineroides (9.8%), An. pullus (6.7%), An. belenrae (1.1%), and An. lesteri (0.5%). Anopheles pullus and An. kleini were collected in greater proportions in May and from May - July, respectively. Few An. sinensis were collected from May - June, but it was the predominant species collected by August, and accounted for >80% of all larvae from September - October. Anopheles kleini was found in all habitats sampled; however, it was collected most frequently in young growth rice paddies, while An. sinensis was collected more frequently in mature and post-harvest paddies. Anopheles pullus was associated with pre-cultivated rice paddies, including water-filled tire ruts left from the previous fall's harvest.

Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic.

The Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) supports and oversees surveillance for emerging infectious diseases, including respiratory diseases, of importance to the U.S. Department of Defense (DoD). AFHSC-GEIS accomplishes this mission by providing funding and oversight to a global network of partners for respiratory disease surveillance. This report details the system’s surveillance activities during 2009, with a focus on efforts in responding to the novel H1N1 Influenza A (A/H1N1) pandemic and contributions to global public health. Active surveillance networks established by AFHSC-GEIS partners resulted in the initial detection of novel A/H1N1 influenza in the U.S. and several other countries, and viruses isolated from these activities were used as seed strains for the 2009 pandemic influenza vaccine. Partners also provided diagnostic laboratory training and capacity building to host nations to assist with the novel A/H1N1 pandemic global response, adapted a Food and Drug Administration-approved assay for use on a ruggedized polymerase chain reaction platform for diagnosing novel A/H1N1 in remote settings, and provided estimates of seasonal vaccine effectiveness against novel A/H1N1 illness. Regular reporting of the system’s worldwide surveillance findings to the global public health community enabled leaders to make informed decisions on disease mitigation measures and controls for the 2009 A/H1N1 influenza pandemic. AFHSC-GEIS’s support of a global network contributes to DoD’s force health protection, while supporting global public health.

Antimicrobial resistance surveillance in the AFHSC-GEIS network

International infectious disease surveillance has been conducted by the United States (U.S.) Department of Defense (DoD) for many years and has been consolidated within the Armed Forces Health Surveillance Center, Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) since 1998. This includes activities that monitor the presence of antimicrobial resistance among pathogens. AFHSC-GEIS partners work within DoD military treatment facilities and collaborate with host-nation civilian and military clinics, hospitals and university systems. The goals of these activities are to foster military force health protection and medical diplomacy. Surveillance activities include both community-acquired and health care-associated infections and have promoted the development of surveillance networks, centers of excellence and referral laboratories. Information technology applications have been utilized increasingly to aid in DoD-wide global surveillance for diseases significant to force health protection and global public health. This section documents the accomplishments and activities of the network through AFHSC-GEIS partners in 2009.

The Global Emerging Infection Surveillance and Response System (GEIS), a U.S. government tool for improved global biosurveillance: a review of 2009

The Armed Forces Health Surveillance Center, Global Emerging Infections Surveillance and Response System (AFHSC-GEIS) has the mission of performing surveillance for emerging infectious diseases that could affect the United States (U.S.) military. This mission is accomplished by orchestrating a global portfolio of surveillance projects, capacity-building efforts, outbreak investigations and training exercises. In 2009, this portfolio involved 39 funded partners, impacting 92 countries. This article discusses the current biosurveillance landscape, programmatic details of organization and implementation, and key contributions to force health protection and global public health in 2009.

A Randomized, Double‐Blind, Placebo‐Controlled Study Evaluating the Efficacy and Safety of Rifaximin for the Prevention of Travelers' Diarrhea in US Military Personnel Deployed to Incirlik Air Base, Incirlik, Turkey

Infectious diarrhea is an important problem among travelers and deployed US military overseas causing substantial morbidity due to acute illness and may result in burdensome postinfectious sequelae. The nonsystemic antibiotic rifaximin was evaluated for prevention of travelers' diarrhea (TD) in a US military and civilian adult beneficiary population in a randomized, double-blind, placebo-controlled clinical trial. In all, 100 volunteers deployed to Incirlik Air Base, Turkey, received rifaximin 1,100 mg once daily or placebo for 2 weeks, and participants were followed daily for 2 weeks. In an intention to treat analysis (n = 95), TD (based on subjects meeting case definition or early treatment) developed in 6.3% (3 of 48) of the rifaximin group compared with 19.2% (9 of 47) in the placebo group (Fisher's exact test p = 0.07). Rifaximin provided 67% (95% confidence interval, -13% to 91%, p = 0.07) protection against TD. Rifaximin 1,100 mg once daily was well tolerated with no observed differences in adverse events, whether solicited or unsolicited among the two treatment groups. Rifaximin may represent an option among military personnel on deployment for prevention of TD with supportive future studies that consider deployment length, settings, and operational situations where widespread use of chemoprophylaxis may increase force health protection without undue risk during critical deployments.

Accelerating Biomedical Research in Designing Diagnostic Assays, Drugs, and Vaccines

The US Department of Defense Biotechnology High-Performance Computing Software Applications Institute for Force Health Protection develops state-of-the-art high-performance computing applications that accelerate biomedical research in the development of diagnostic assays, drugs, and vaccines. The BHSAI works together with DoD life scientists to develop and integrate HPC software applications into DoD biomedical research programs.

Residual Mosquito Barrier Treatments on U.S. Military Camouflage Netting in a Southern California Desert Environment

Treating perimeters of vegetation with residual insecticides for protection from mosquito vectors has potential for U.S. military force health protection. However, for current U.S. military operations in hot-arid environments with little or no vegetation, residual applications on portable artificial materials may be a viable alternative. We evaluated bifenthrin residual treatments of U.S. military camouflage netting under hot-arid field conditions in a desert area in southern California exposed to abundant wild Culex tarsalis mosquitoes. We assessed the ability of the treatment to reduce the numbers of mosquitoes penetrating perimeters of netting and reaching CO2-baited mosquito traps. Treated camouflage netting barriers reduced mosquitoes by > or = 50% for 7-14 days and by 20-35% for 21-28 days compared to untreated barriers. Although reductions may be translated into reductions in risk of exposure to mosquito-borne diseases, we emphasize that barrier treatments should be a component in a suite of insect control measures to be effective.

Evaluation of ULV and Thermal Fog Mosquito Control Applications in Temperate and Desert Environments

Ultra-low-volume (ULV) and thermal fog aerosol dispersals of pesticides have been used against mosquitoes and other insects for half a century. Although each spray technology has advantages and disadvantages, only 7 studies have been identified that directly compare their performance in the field. US military personnel currently operating in hot-arid environments are impacted by perpetual nuisance and disease vector insect problems, despite adulticide operations using modern pesticide-delivery equipment such as ULV. None of the identified comparative studies has looked at the relative feasibility and efficacy of ULV and thermal fog equipment against mosquitoes in hot-arid environments. In this study we examine the impact of ULV and thermal fog applications of malathion against caged sentinel mosquitoes in the field in a warm temperate area of Florida, followed by a similar test in a hot-dry desert area of southern California. Patterns of mortality throughout 150 m x 150 m grids of sentinel mosquitoes indicate greater efficacy from the thermal fog application in both environments under suboptimal ambient weather conditions. We discuss the implications of these findings for future military preventive medicine activities and encourage further investigations into the relative merits of the 2 technologies for force health protection.

Preparing Military Installations for Pandemic Influenza Through Tabletop Exercises

Effective Department of Defense (DoD) response to pandemic influenza requires robust and well-exercised plans at the installation level. This article describes proceedings and key findings from a half-day "train-the-trainer" pandemic influenza tabletop exercise for Tri-Service installation public health emergency officers (PHEOs) at the August 2008 Force Health Protection conference. Exercise participants were expected to facilitate the execution of a pandemic influenza exercise at their respective installations within 6 months of attendance. On a 6-month follow-up survey (N= 50), 68% indicated their installations had since created a new pandemic influenza plan or revised an existing one, whereas 44% indicated that their installation had since conducted a pandemic influenza exercise. Chief reported barriers to conducting installation-level pandemic influenza exercises included competing priorities, followed by time, personnel, and budget limitations. Relevant policy implications for installation-level pandemic influenza readiness include access to higher level plans, strategic utilization of assets to optimize surge capacity, and cross-training of personnel.

Zoonotic And Infectious Disease Surveillance In Central America: Honduran Feral Cats Positive For Toxoplasma, Trypanosoma, Leishmania, Rickettsia, And Lyme Disease

A recent zoonotic and infectious disease field surveillance study in Honduras resulted in the discovery of Toxoplasma, Trypanosoma, Leishmania, Rickettsia, and Lyme disease with statistically high prevalence rates in a group of feral cats. All five diseases--Toxoplasmosis, Trypanosomiasis, Leishmaniasis, Rickettsiosis, and Lyme disease--were confirmed in this group of cats having close contact to local civilians and U.S. personnel. These diseases are infectious to other animals and are known to infect humans as well. In the austere Central and South American sites that Special Operations Forces (SOF) medics are deployed, the living conditions and close quarters are prime environments for the potential spread of infectious and zoonotic disease. This study?s findings, as with previous veterinary disease surveillance studies, emphasize the critical need for continual and aggressive surveillance for zoonotic and infectious disease present within animals in specific areas of operation (AO). The importance to SOF is that a variety of animals may be sentinels, hosts, or direct transmitters of disease to civilians and service members. These studies are value-added tools to the U.S. military, specifically to a deploying or already deployed unit. The SOF medic must ensure that this value-added asset is utilized and that the findings are applied to assure Operational Detachment-Alpha (SFOD-A) health and, on a bigger scale, U.S. military force health protection and local civilian health.

A Robust, Multi-criteria Modeling Approach for Optimizing Aeromedical Evacuation Asset Emplacement

According to current force health protection policy, the U.S. Army’s Health Service Support system is designed to maintain a healthy force and to conserve the combat strength of deployed soldiers. Specifically, this system remains particularly effective by employing standardized aeromedical evacuation assets and providing a responsive field-sited medical treatment facility for the wounded soldiers evacuated from the battlefield. Since the beginning of Operation Enduring Freedom, military commanders have faced a significant combinatorial challenge integrating these life-saving yet limited air evacuation assets into a fully-functional, comprehensive system for the entire theatre, which deserves thorough analysis for decision-making. This work describes a robust, multi-criteria decision analysis methodology using a scenario-based, stochastic optimization goal-programming model that U.S. Army medical planners can use as a strategic and tactical aeromedical evacuation asset-planning tool to help bolster and improve the current air evacuation system in Afghanistan. Specifically, this model optimizes over a set of expected scenarios with stochastically-determined casualty locations to emplace the minimum number of helicopters at each medical treatment facility necessary to maximize the coverage of the theatre-wide casualty demand and the probability of meeting that demand, while minimizing the maximal medical treatment facility evacuation site total vulnerability to enemy attack.

Nonbattle Injury Among Deployed Troops: An Epidemiologic Study

(n = 150) Nonbattle injury (NBI) continues to be a leading cause of morbidity among troops currently deployed to Iraq and Afghanistan. To assess NBI incidence, impact, and risk factors, a survey was given to soldiers during mid- or postdeployment from Iraq, Afghanistan, and surrounding region, from January 2005 through May 2006. Among 3,367 troops completing a survey, 19.5% reported at least one NBI, and 85% sought care at least once for their symptoms. Service component, rank, and unit type were among factors associated with differential NBI risk. Twenty percent stated that NBI resulted in back-up personnel being called or shift change to cover impacted duties, and among those reported having been grounded from flight status, a third were the result of NBI. NBI continues to be a problem in recent deployments, and given the findings on individual and potential operational impact indicators, NBI should be viewed as a primary force health protection problem.

Warfighter Nutrition: Current Opportunities and Advanced Technologies Report From a Department of Defense Workshop

The Uniformed Services University hosted a conference in July 2008 entitled "Warfighter Nutrition: Advanced Technologies and Opportunities" with Health Affairs and the Defense Advanced Research Projects Agency to develop strategic and tactical plans that could enhance Force Health Protection (FHP) by optimizing warfighter nutrition within the Department of Defense (DoD). The conference focused on three aspects of military nutrition: (1) fueling the forces, or garrison feeding; (2) performance optimization or operational feeding during deployment; and (3) nutritional interventions to support health reset and healing. Presentations by speakers addressed practical interventions (i.e., ready for implementation now) and advanced technologies (i.e., approaches meriting prioritized research and development efforts to transition into application). The conference concluded that nutritional optimization represents an integral and proactive approach to prevent illness, injury, and performance degradation throughout all phases of military service. The overarching consensus achieved was that warfighter nutrition, as a cornerstone of FHP, warrants the critical attention of both medical and line leadership to move quickly to support current initiatives and future advanced technologies.

Force Health Protection: The Mission and Political Context of the Longitudinal Health Record

Drawing upon an extensive search of publically available literature and discussions at the "National Forum on the Future of the Defense Health Information System," this article documents the evolving mission and political context of the longitudinal health record (LHR) as an instrument for Force Health Protection (FHP). Because of the Gulf War syndrome controversy, the Department of Defense (DoD) launched an ambitious, complex series of programs designed to create a comprehensive, integrated defense health surveillance capability to assure FHP and keep faith with the American people. This "system of systems" includes individual component systems to perform specific functions such as disease surveillance, battlefield assessment, and patient care and consolidates these diverse types of information into centrally accessible archives that serve the interests of occupational health, preventive medicine, medical strategic planning, and longitudinal patient health care. After 25 years of effort and major accomplishments, progress toward a LHR remains uneven and controversy persists.

Protecting the Health of U.S. Military Forces in Romania: Endemic Disease Threat Considerations

In 2005 the United States and Romania signed a historic access agreement establishing the first U.S. military bases in the former Soviet bloc country of Romania. The bases will host joint exercises aimed at developing regional military cooperation with forces throughout the entire 92-country USEUCOM area of responsibility (AOR). These forward operating bases (FOBs) or "lily pads" will include the Smârdan Training Range, Babadag Training Range, Mihail Kogălniceanu (MK) Air Base, and Cincu Training Range. They will be under the command of Joint Task Force East (JTF-East), headquartered at the MK Air Base. Here described are the naturally occurring pathogens of clinical significance that exist in the region, including those of known biowarfare/bioterrorism (BW/BT) potential. Notwithstanding the length of deployment for training, proactive clinical and environmental surveillance should be linked to the implementation of adequate Force Health Protection (FHP) measures to minimize the impact these medical threats may have on JTF-East operations.

Advances in Hearing Conservation Practices: An Interview With Mark Stephenson

Abstract It is estimated that 30 million Americans are exposed to hazardous noise levels at work (Stephenson et al., 2003). The Occupational Safety and Health Act of 1970 created two separate agencies dedicated to promoting worker health and safety: the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH). Research at NIOSH informs OSHA regulations. This report comprises an interview with Mark Stephenson, PhD, Scientific Research Coordinator for the NIOSH noise and hearing loss research program. He provides insights into the latest advances in hearing conservation practices, what works and why. Current hearing conservation practices developed at NIOSH and not yet mandated by OSHA use methods borrowed from evidence-based health communication theories to change the ways individuals view the problem of noise exposure, eliminate barriers that prevent effective hearing protector use, and create a culture of self-efficacy with respect to hear...

Acute Gastrointestinal Infection, Respiratory Illness, and Noncombat Injury Among US Military Personnel During Operation Bright Star 2005, in Northern Egypt

In the fall 2005, approximately 7,500 US military personnel participated in an exercise in the Egyptian desert. The epidemiology of disease and noncombat injury among deployed troops is important in the context of assessing current mitigation strategies and the development of future ones. To assess the prevalence and impact of diarrhea and enteropathogen distribution, we conducted a case series study. To assess the relative impact of diarrhea compared to respiratory infection and injury, we conducted a post-deployment survey and compared these data to clinic-based syndromic surveillance data. We enrolled 43 patients with acute diarrhea, 21 (49%) having one or more pathogens isolated. Enterotoxigenic Escherichia coli (n= 16), enteroaggregative E coli (n= 3), and Shigella spp. (n= 3) were the most common pathogens identified. Respiratory illness had the highest incidence (73 episodes/100 person-months) compared to diarrhea (35 episodes/100 person-months) and noncombat injury (17 episodes/100 person-months), though noncombat injury more frequently resulted in lost duty days and health-care utilization. Noncombat injuries and illnesses have had a significant impact on military missions and continue to result in force health protection challenges today. Future studies are needed to test and evaluate countermeasures to mitigate these illnesses and injuries to increase the health of the individuals and optimize mission readiness.

Canadian Forces Evaluation of the EPINATO Health Surveillance System in Bosnia-Herzegovina

The Canadian Forces (CF) adopted the EPINATO surveillance system in 1996 to monitor disease and injury morbidity in deployed settings. The Directorate of Force Health Protection, CF Health Services Group initiated an evaluation of EPINATO in Task Force Bosnia-Herzegovina in August 2003. Two methods were used to assess coding reliability: a chart audit and Sick Parade Register review. Stakeholder interviews were conducted evaluating data flow, reporting structure, and key system attributes. Reliability (K, 95% confidence interval) was good in 4 of 24 categories--sexually transmitted diseases, K = 0.75 (0.50, 1.00); eye disorders, K = 0.51 (0.15, 0.88); ears/nose/ throat, K = 0.51 (0.33, 0.69); lower respiratory infections, K = 0.49 (95% confidence interval 0.34, 0.65)-but otherwise was poor. EPINATO is not an effective, reliable tool for CF deployment health surveillance. An improved health surveillance system is required to ensure disease and injury aberrations are detected and optimal preventive programs and policies are in place for deployed CF military members.

Preventive Medicine in Task Force 1st Armored Division During Operation Iraqi Freedom

Task Force 1st Armored Division (TF1AD) deployed to Baghdad and South Central Iraq from April 2003 through July 2004. TF1AD preventive medicine had responsibility for ensuring divisional force health protection, including soldier health, disease and nonbattle injury mitigation, health promotion, and civil affairs operations. Heat injury, diarrheal disease, skin and respiratory disease, and eye and musculoskeletal injury rates were high. Command emphasis and preventive medicine action resulted in better living conditions and personal sanitation. To counter the threat, the TF1AD preventive medicine/ division surgeon team used a "spiraling out" approach that focused attention first on hand-washing, potable water, vector control, waste disposal, and food sanitation and later on noise, asbestos, environmental contamination, and radiation. In April 2004, TF1AD shifted focus to the Multinational Division Central-South region of Iraq and many similar problems occurred as in May 2003, although they were less severe, in part because of the lessons learned in Baghdad.

Treatment of Psychiatric Disorders Onboard an Aircraft Carrier Assisted with Psychotropic Medication: A Retrospective Review Describing One Aspect of Navy Force Health Protection

Navy clinical psychologists, assigned to aircraft carriers, are playing an increasing role in not only implementing Navy force health protection, but also in further specializing the delivery of mental health evaluation, treatment, and disposition services at the "tip of the spear." An aircraft carrier's medical department, augmented with a clinical psychologist, is now better able to coordinate diagnostic, psychotropic, and psychotherapeutic treatments for both shipboard and air wing personnel. This retrospective review reports the outcomes of a 6-month treatment program for personnel, assigned to the USS Constellation (CV-64), who were prescribed a psychotropic medication while receiving psychotherapy. We concluded that psychotropic medications can be safely and effectively used onboard an aircraft carrier. Furthermore, personnel prescribed psychotropic medication successfully completed their assigned duties and obtained recommendations for advancement and retention. Lastly, our medical department proactively fulfilled the Navy force health protection tenet of preserving a healthy and fit force.