Public Health: The Cornerstone of a System for Health

October–December 2016

2014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools

in Harris County and the City of Houston, Texas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Yvonne H. Randle; Cheryl Battle Freeman; Monique Jackson; Martin Reyna, MS; Mustapha Debboun, PhD, BCE

A Multiagency Approach to Reducing West Nile Virus Risk in Richmond County, Georgia, in 2015 . . . . . . . 9

Rosmarie Kelly, PhD, MPH; Fred Koehle; Oscar P. Flite III, PhD; R. Chris Rustin, DrPH, MS, REHS

Protection of Military Personnel Against Vector-Borne Diseases: A Review of Collaborative Work

of the Australian and US Military Over the Last 30 Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Stephen P. Frances, PhD; Michael D. Edstein, PhD; Mustapha Debboun, PhD, BCE; G. Dennis Shanks, MD

Emerging Tick-borne Rickettsia and Ehrlichia at Joint Base Langley-Eustis, Fort Eustis, Virginia . . . . . . . . . 22

Melissa K. Miller, MS; Ju Jiang; Melissa Truong; Tamasin Yarina; et al

Honey Bee Swarms Aboard the USNS Comfort: Recommendations for Sting Prevention,

Swarm Removal, and Medical Readiness on Military Ships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

LCDR James C. Dunford, MSC, USN; CDR Karl C. Kronmann, MC, USN; et al

Mortality From Fungal Diseases in the US Air Force From 1970 to 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Richard K. Kugblenu, MPH; Will K. Reeves, PhD, MS

Does Reducing Time to Identification of Infectious Agents Reduce Incidence Rates 

of Norovirus in a Population Deployed to Southwest Asia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

LTC Kip R. Thompson, MS, USAR; MAJ Eric C. Mossel, MS, USAR; et al

Hearing Loss and Tinnitus in Military Personnel with Deployment-Related Mild Traumatic Brain Injury . . 52

Stephanie J. Karch, AuD, PhD; LTC José E. Capó-Aponte, SP, USA; LTC D. Scott McIlwain, SP, USA, et al

Going GLP: Conducting Toxicology Studies in Compliance with Good Laboratory Practices . . . . . . . . . . . . . 64

LTC Erica Eggers Carroll, VC, USA

An Expression of Change: Breastfeeding in the Military . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Joseph B. Topinka, JD, MHA, MBA; Linda R. Turner, MLS; Kim Lee, PT, PhD; MAJ Jodi Brown, AN, USA

Chemical Weapons Exposures in Iraq: Challenges of a Public Health Response a Decade Later . . . . . . . . . 75

Coleen Baird, MD, MPH; MAJ Raul Mirza, MC, USA; Jessica Sharkey, MPH; Ron Teichman, MD, MPH; et al

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Capt Matthew Barnes, USMC; Coleen Baird, MD, MPH; Capt Anthony Suh, USMC; Capt John Crutchfield, USMC; et al

Animal-Assisted Health and the Performance Triad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

MAJ M. Todd French, VC, USA

Service Animals: A New Legal Dimension Within the US Military . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Joseph B. Topinka, JD, MHA, MBA, LLM; Jack Nichols, JD; Matthew Brooks, PhD

Spurgeon Neel Annual Writing Award Top Essays

Grace Under Fire: The Army Nurses of Pearl Harbor, 1941 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

Gwyneth R Milbrath, RN, MSN, MPH

Military Medicine of the Russo-Japanese War and its Influence on the

Modernization of the US Army Medical Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Justin Barr, MD

JOURNAL

THE UNITED STATES ARMY

MEDICAL DEPARTMENT
JOURNAL

A Professional 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

October–December 2016 US Army Medical Department Center & School PB 8-16-10/11/12

The Army Medical Department Journal [ISSN 1524-0436] is published

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DISTRIBUTION: Special 1621402

LTG Nadja Y. West

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US Army Medical Department Center and School

US Army Health Readiness Center of Excellence
October – December 2016 1

2014: A Record-Breaking Year for

 West Nile Virus Positive Mosquito Pools in

 Harris County and the City of Houston, Texas

Yvonne H. Randle Martin Reyna, MS

Cheryl Battle Freeman Mustapha Debboun, PhD, BCE*

Monique Jackson

Abstract

In the 14 years since the emergence of West Nile virus (WNV) in Harris County and the city of Houston, Texas, 

the number of mosquitoes infected with the virus has fluctuated with several high and low count years. During this 14-year period, mosquito surveillance operational areas in Harris County were expanded from 248 to 

268 and the distribution of the virus activity in mosquitoes varied from year to year. Operational areas with 

WNV infected mosquitoes increased from 137 in 2002 to 197 in 2006, decreased to 71 areas in 2007, and to an 

all-time low of 18 in 2008. The number increased to 78 areas in 2009, 96 in 2010, 133 in 2011, and 177 in 2012, 

but fell to 73 in 2013. However, 234 areas were confirmed in 2014, and only 138 in 2015. The WNV transmission was high in 2002 with 227 WNV positive mosquito pools. The number of positive mosquitoes remained 

elevated for a number of years and then declined from 2007 to 2010. Three record high years for WNV activity 

were: 2005, 2006, and 2011 with 698, 838, and 605 confirmed positive mosquito pools, respectively. Viral activity declined in 2012, followed by a marked decline in 2013 with only 147 WNV positive mosquito pools. In 

2014, a record-breaking number of 1,286 WNV positive mosquito pools were confirmed in Harris County and 

the city of Houston, the most ever in a single season, while 406 were confirmed in 2015.

West Nile virus (WNV) is a mosquito-transmitted, 

arthropod-borne virus maintained in nature in a birdmosquito transmission cycle. It belongs to the genus 

Flavivirus (family Flaviviridae) and is closely related to 

St Louis encephalitis (SLE) virus. Humans, horses, and 

other vertebrates are dead-end hosts that do not produce 

significant viremia and thus do not contribute to the 

transmission cycle.1

 Prior to 1999, WNV was geographically distributed in Africa, the Middle East, India, and 

western and central Asia, with occasional epidemics occurring in Europe.2

 During the summer of 1999, WNV 

was detected in New York and has since emerged in all 

48 contiguous states of the United States (not in Alaska 

and Hawaii) and other areas of the Americas including 

Canada, Mexico, and the Caribbean Islands.3,4 It was introduced into Harris County (HC), including the city of 

Houston, Texas, during the summer of 2002 with virus 

outbreaks occurring each year thereafter.5

 The primary 

vector of WNV in HC is the Culex quinquefasciatus Say

mosquito.

The emergence of WNV into HC and the Houston metropolitan area in 2002 brought about major changes in 

mosquito surveillance and testing for arboviruses at 

Harris County Public Health, Mosquito Control Division 

(MCD). Prior to that, the main focus for surveillance, 

testing, and control was SLE virus which then shifted 

to WNV. Between 2002 and 2005, mosquito monitoring 

and trapping were expanded from 248 to 268 operational areas within HC and Houston (Figure 1).

The enzyme-linked immunosorbent assay (ELISA) antigen capture assay, originally developed for SLE, was 

adapted for WNV.6

 Subsequently, the number of specimens being tested increased dramatically. The Rapid 

Analyte Measurement Platform (RAMP) test (Response 

Biomedical Corp, Burnaby, British Columbia, Canada), 

a rapid and accurate WNV antigen assay, was successfully incorporated into the testing program in 2003.7

Because the MCD vector control decisions were based 

upon mosquito surveillance and virology laboratory test 

data, the time between submitting mosquito samples for 

testing and receiving test results initially posed a significant limitation. Mosquito pool samples were tested in 

weekly batches and the lag time from collection to obtaining test results was usually a week or longer. Changes in the surveillance and virology laboratory testing 

schedules and timelines were implemented in 2005-

2006. Specimen processing, ELISA, and RAMP testing 

*The US Army Medical Department (AMEDD) Journal thanks Dr Debboun for his work developing this issue focused on public health. He coordinated and managed the call for manuscripts, then the review and selection of the content, as he has done annually developing similar 

issues since 2006. When he retired as a Colonel from the US Army, he was Director of the Department of Preventive Health Services at the 

AMEDD Center and School and Chairman of the Editorial Review Board of the AMEDD Journal at Fort Sam Houston, San Antonio, Texas.
2 http://www.cs.amedd.army.mil/amedd_journal.aspx

were then conducted 3 times per week. Consequently, 

the gaps between collection, testing, and reporting of 

results were narrowed to 3 days, which also expedited 

control efforts.

Detailed mosquito surveillance and testing records were 

recorded in a Microsoft Access database maintained by 

the Technical Operations Branch of the MCD. At the end 

of each year, the data was analyzed and reported in the 

Annual Summary Reports of Mosquito Surveillance and 

Virology Laboratory Test Results for the years 2002-2015.

Materials and Methods

In pretest preparations in the virology laboratory at 

MCD, pooled samples of Cx quinquefasciatus mosquitoes were placed in microcentrifuge tubes with a bovine 

albumin buffered solution (BA-1) and one steel bead per 

tube. The specimens were ground in Qiagen TissueLyser II mills (Qiagen Sciences, Inc, Germantown, MD), 

and clarified by centrifugation. The mosquito homogenates were screened by ELISA Antigen Capture Assay for both SLE and WNV.6

 An ELISA plate reader 

(BioTek EL800), in conjunction with BioTek KCJunior 

software (BioTek Instruments, Inc, Winooski, VT) were 

used to measure the degree of color development and 

light absorption within the individual test plate wells. 

The reader/software system determined the amount of 

antigen in each sample and calculated the mean optical 

density (OD) value of each set of duplicate test wells. 

Positive ELISA tests were determined by comparing the 

samples’ OD values to the mean OD of the negative controls.The resulting data was exported to a Microsoft Excel spreadsheet to tabulate the comparative values. The 

WNV ELISA positive pools were further tested by the 

RAMP test (ADAPCO, Sanford, FL) for confirmation.

The RAMP WNV assay is an immunochromatographic 

test for detection of WNV in mosquitoes. A measured 

amount of the test samples in RAMP buffer was transferred to the sample well of the WNV test cartridge (TC) 

using a pipette and the supplied assay pipette tip. The 

TC uses latex particles that are fluorescently labeled and 

tagged with WNV antibodies. As the sample migrated 

through the cartridges, WNV antigen bound particles 

2014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools

in Harris County and the City of Houston, Texas

Figure 1. Mosquito surveillance map showing 268 mosquito control operational areas in Harris County, which includes the city of 

Houston, Texas.
October – December 2016 3

The Army Medical Department Journal

were immobilized at the detection zone by specific antibodies and a portion of excess (control) particles were 

immobilized at the internal control zone.8

The RAMP reader measured the amount of fluorescence 

emitted by the particles bound at each zone and calculated a ratio between the measurements.7

 The results 

were displayed as a numerical value (RAMP units) on 

the reader screen. From 2003 to 2013, mosquito pools 

with RAMP units greater than or equal to 2.4 were confirmed as WNV positive. This low value was determined 

to be acceptable after discussions with the manufacturer 

showed that the BA1 grinding buffer used in the MCD 

virology laboratory affected the reading curve of the 

RAMP system. In 2014, the negative cut-off value was 

changed after the lowest numerical value displayed for 

the RAMP WNV test was revised by the manufacturer 

to 10.0 units (from 2.4). Results below 10.0 display as 10 

units or less and are considered negative. These updated 

values were used in both 2014 and 2015 for confirmation 

of WNV ELISA positive pools.

Results

The distribution of virus activity in mosquitoes in the 

268 surveillance areas varied similarly to the number of 

positive mosquitoes. As shown in Figure 2, over the last 

14 years, the number of areas with confirmed WNV positive mosquitoes varied from year to year. There were 

137 infected areas in 2002 and about the same number of 

areas in 2003 and 2004. The number increased to 175 in 

2005 and to 197 in 2006. There was a drastic decrease to 

71 areas in 2007 and an all-time low of 18 in 2008. The 

number of positive areas rose to 78 in 2009, 96 in 2010, 

and 133 in 2011. The number spiked to 177 in 2012, then 

drastically dropped to 73 areas in 2013. In 2014, an unprecedented 234 WNV positive areas were confirmed, 

while only 138 in 2015.

Records in the mosquito surveillance database show 

that the inner Highway 610 Loop areas, Kingwood in 

northeast HC, and the northwest quadrant of HC provided hot spots of viral activity during the majority of 

the peak mosquito seasons. From 2009 to 2013, heavy 

concentrations of WNV were also found in the southeast, southwest, north-central, and far west areas.

Due to the widespread presence of WNV, the number of 

Cx quinquefasaciatus and other mosquito species (Aedes albopictus Skuse and Ae aegypti (L.)) tested more 

than doubled after 2002. In 2002, 7,298 mosquito pools 

were tested, and more than 11,000 were tested annually 

beginning in 2003 (Figure 3). The numbers progressively increased, reaching a record of approximately 

16,750 mosquito pools screened for WNV and SLE in 

both 2008 and 2009. In 2010, there was a decrease in 

the number of mosquito pools tested (13,860), but an increase in 2011 (14,396) due to increased viral activity.

In 2012 and 2013, fewer than 15,000 samples were tested 

each year. Surveillance and testing continued throughout the winter months but with lower numbers of mosquitoes. However, in 2014, more than 10,000 mosquito 

pools were tested in the first 10 of 20 weeks and 2,600 

additional mosquito pools were tested in the latter 10 of 

the 20 weeks, culminating in a season total of 12,608. 

In 2015, 13,877 pooled mosquito samples were tested 

between January and the end of December, resulting in 

1,269 more pools than 2014.

137 130 139

175

197

71

18

78

96

133

177

73

233

138

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

0

100

200

250

50

150

WNV Positive Surveillance Areas

Figure 2. Number of surveillance areas with confirmed WNV positive Culex quinquefasciatus mosquito pools identified in 

Harris County, including the city of Houston, Texas, each year from 2002 to 2015.
4 http://www.cs.amedd.army.mil/amedd_journal.aspx

Over the past 14 years, the number of mosquitoes infected with WNV in HC and Houston fluctuated with 

several high count years, and a few years with very low 

numbers (Figure 4). The number of WNV positive mosquitoes remained elevated for a number of years and 

then declined from 2007-2010. The years 2005 and 2006 

had high numbers (805 and 838) of WNV positive mosquito pools. Similarly, 2011 had a high number of virus 

activity with 605 confirmed WNV positive mosquito 

pools. There was a decline in WNV activity (227) in 

2012, followed by a marked decline in 2013 with only 

147 WNV positive mosquito pools.

In 2014, the first WNV positive mosquitoes were detected in week 23 (June 6). The numbers steadily increased 

each week thereafter until reaching 1,286 confirmed 

WNV positive mosquito pools in a single summer season, far surpassing those of any of the previous 12 years. 

In the second week of July, more than 100 positive 

samples were confirmed each week for 7 weeks. The 

peak of viral activity occurred in 

week 30 (July 20-26), with a record number of 168 WNV positive mosquito pools. The number 

of positive pools began declining in late August with a reduction of nearly 50% or less each 

week until the end of September when only 9 WNV positive 

mosquito pools were detected 

and confirmed. Additionally, 7 

more were confirmed positive 

for week 40 on October 3, 2014. 

The total number of confirmed 

WNV positive mosquito pools 

for 2015 was 406, a reduction of 

more than 800 from 2014.

In HC and Houston, mosquito surveillance collection records and test results 

were recorded in a database according to 

weekly calendars of each year (Table 1). 

A detailed analysis of the virus transmission period, during each of the 14 years 

of virus outbreaks showed that a peak 

in the number of confirmed WNV positive mosquitoes occurred in weeks 30 to 

32 (July 26-August 15) in 12 of 14 years. 

However, in 2007, the greatest number of 

positive WNV mosquito pools occurred 

later in the year (week 42, October 14-20), 

while early in 2008 (week 22, May 25-31) 

as shown in Table 2.

In 2002, the first detection of WNV positive mosquito 

pools occurred in the second week of June (week 24, 

June 9-15). Detection of WNV positive mosquito pools 

continued over a 20 week period from June to November. 

The highest number of positives (32) occurred in week 

31 (July 28-August 3). In 2003, WNV was detected over 

24 weeks from May to November. Week 30 (July 20-26) 

had the highest number of positive mosquitoes with 64 

confirmed infected pools. In 2004, WNV was detected 

from June to December over a period of 27 weeks. The 

peak number of positives was 65 in week 30 (July 25-31). 

In 2005, it was found from May to October, over a 22 

week period with a peak number of 137 in August. Although there was a longer mosquito WNV detection period in 2004, the number of positive samples was lower 

than that of 2005.

In 2006, the mosquito WNV transmission period was 

the longest of the years studied with a duration of 31 

weeks from May 9 to December 6. The peak activity 

2014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools

in Harris County and the City of Houston, Texas

Figure 4. The number of mosquito pools in which mosquitoes infected with WNV were detected in Harris County, including the city of Houston, Texas, 2002 to 2015.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

23 86

227

239

147

598 605

399 406

838

501

805

262

1286

800

1,000

200

0

600

1,200

400

1,400

Number of WNV Positive Mosquito Pools

Figure 3. Number of Culex quinquefasciatus mosquito pools tested annually for 

WNV in Harris County, including the city of Houston, Texas, 2002 to 2015.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

6,000

18,000

0

12,000

8,000

2,000

14,000

10,000

4,000

16,000

Number of Mosquito Pools
October – December 2016 5

The Army Medical Department Journal

of 97 positive pools was confirmed in the week of July 

30-August 5 (31st week of 2006). In 2007, mosquito 

WNV activity was confirmed over a period of 18 weeks 

from June to November with a peak of 11 positive pools 

in week 42 (October 14-20).

In 2008, mosquito WNV was detected over a period of 

13 weeks between April and October. The peak number 

of positives was 6 in week 22 (May 25-31). The virus was 

detected from May to October in 2009, with a high number of 30 positive pools in week 30 (July 26-August 1).

In 2010, the virus activity period extended for 22 weeks 

from June to December, peaking at 40 positive pools 

in week 33 (August 10-16). In 2011, WNV in mosquitoes was detected over 24 weeks from May to November 

with a peak number of 87 positive pools during week 32 

(August 7-13). The season extended from May to November for 25 weeks in 2012 with a peak number of 72 

positive pools in week 32 (August 5-11). In 2013, the 

virus was detected from June to November for 19 weeks 

with a peak of 19 positive mosquito pools in week 32 

(August 4-10).

In 2014, the first confirmed WNV positive mosquito pool was detected on June 

6. Beginning in the second week of July 

(week 28, July 06-12), over 100 positive 

samples were confirmed each week for 

7 weeks. The period of high mosquito 

WNV risk extended for 18 weeks with 

a peak total of 168 positive pools during week 30 (July 20-26). The number of 

positive pools decreased in late August 

(August 26-29), with a reduction of nearly 

50% or less each week until the end of 

September. Detection of WNV positive 

mosquito samples continued into October with 15 positive mosquito pools confirmed on October 16, 2014.

The 2015 WNV mosquito season began in June with 

a confirmation of the first positive mosquito pools on 

June 16 (week 24), and continued until week 46 in midNovember. The highest number of positive pools (58) 

was detected in week 30 (July 26–August 1) and closely 

mirrored the following week (August 2-8) with 54 confirmed WNV positive mosquito pools. The season ended with a total of 406 WNV positive mosquito pools.

The areas of Harris County which were confirmed with 

mosquito WNV activity in 2013 are shown in Figure 

5. Positive areas are highlighted with red stripes and 

dots. Heaviest concentrations of mosquito WNV activity were in the northern areas with scatterings in the far 

west, southwest, and southeast quadrants of HC. Areas 

inside the I-610 Loop were not as involved as in past 

years, and only 73 of the 268 areas county-wide were 

confirmed positive with WNV in mosquitoes.

In the viral activity map of 2014 (Figure 6), nearly the 

entire county was highlighted in red stripes and dots; 235 

(87.7%) areas of the 268 surveillance/operational areas. A map of 

mosquito-borne disease activity 

for 2015 is shown in Figure 7. The 

WNV in mosquitoes was detected 

and confirmed in 138 (51.4%) operational areas. The highest proportion of WNV positive mosquitoes in 2015 were detected in areas 

in the southwest sectors within the 

I-610 loop. Other highly infected 

areas were located in the southwest and far west sections of HC. 

A cluster of the virus was also 

detected in 10 areas in Baytown, 

located in the easternmost sector 

of Harris County.

Table 1. Week numbering assignments for collection/test results database purposes relative to calendar months of 2002 to 2015.

Weeks assigned to

calendar months for:

2002, 2003, 2007,

2008, 2013, 2014

Weeks assigned to

calendar months for:

2004, 2005, 2006, 2009,

2010, 2011, 2012, 2015

Month Weeks Month Weeks Month Weeks Month Weeks

January 01-05 July 27-31 January 01-04 July 26-30

February 06-09 August 32-35 February 05-08 August 31-34

March 10-13 September 36-39 March 09-12 September 35-39

April 14-18 October 40-44 April 13-17 October 40-43

May 19-22 November 45-48 May 18-21 November 44-47

June 23-26 December 49-52 June 22-25 December 48-52

Table 2. Mosquito WNV detection period and weeks with the highest number of positive 

mosquito pools from 2002 to 2015

Variable 2002 2003 2004 2005 2006 2007 2008

Virus Detection 

Period

Jun-Nov

20 weeks

May-Nov

24 weeks

Jun-Dec

27 weeks

May-Oct

22 weeks

May-Dec

31 weeks

Jun- Nov

18 weeks

Apr-Oct

13 weeks

Week No/Peak 

No. Positives 31/32 30/64 30/65 32/137 31/97 42/11 22/6

Total No. WNV 

Confirmed 227 399 598 698 838 86 23

Variable 2009 2010 2011 2012 2013 2014 2015

Virus Detection 

Period

May-Oct

19 weeks

Jun-Dec

22 weeks

May-Nov

24 weeks

May-Nov

25 weeks

Jun-Nov

19 weeks

Jun-Oct

18 weeks

Jun-Nov

25 weeks

Week No/Peak 

No. Positives 30/30 33/40 32/87 32/72 32/19 30/168 30/58

Total No. WNV 

Confirmed 239 262 605 501 147 1,286 406
6 http://www.cs.amedd.army.mil/amedd_journal.aspx

Summary

Based on the data collected since WNV’s emergence 

into HC and Houston, mosquito WNV cases typically 

began in May or June, and declined to low levels in October or November. However, in 2004, 2010, and 2006, 

the WNV season extended into December. In 2008, it 

began early in April, and extended until October for a 

period of only 13 weeks. Six mosquito WNV outbreaks 

began in May (2003, 2005, 2006, 2009, 2011, 2012), and 

seven in June (2002, 2004, 2007, 2010, 2013, 2014, 2015). 

Four ended in October (2005, 2008, 2009, 2014), seven 

in November (2002, 2003, 2007, 2011, 2012, 2013, 2015) 

and three in December (2004, 2006, 2010).

The length of the mosquito WNV detection period had 

no indication of the amount of WNV detected and had 

no bearing on the number of positive mosquito pools 

confirmed. In 2014, which had the highest number ever 

of confirmed positive mosquito pools (1,286), WNV 

was detected for 18 weeks, matching 2007 which had 

only 86 positive mosquito pools. The shortest detection 

period was in 2013, lasting only 13 weeks with 23 WNV 

positive mosquito pools. The longest period was in 2006 

which extended for 31 weeks, resulting in 838 positive 

pools. Each of the 14 years had a peak of WNV activity during late July and August (weeks 30-33), with the 

exception of 2007 and 2008 which had the most in week 

42 (October) and week 22 (May), respectively.

The distribution pattern of viral activity within the surveillance areas of HC in any given year was equally unpredictable because it differed from year to year. Areas 

within the I-610 Loop in the heart of Houston figured 

prominently, providing hot spots of viral activity during 

2014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools

in Harris County and the City of Houston, Texas

Figure 5. Map of Harris County, Texas, showing 72 areas (27%) with confirmed WNV positive mosquito pools (147) in 2013. Positive 

areas are highlighted with red stripes and dots.
October – December 2016 7

The Army Medical Department Journal

10 of the 14 years (2002-2006, 2008, 2009, 2011, and 

2014). Four years (2007, 2010, 2012, and 2013) had minimal WNV activity within the I-610 loop but more in 

the southwest, far west, northwest, and northeast sectors of HC. In 2004, 2005, 2006, 2011, and 2014, there 

were high numbers of confirmed WNV positive mosquito pools over multiple weeks in areas within the I-610 

Loop, as well as northwest and northeast HC that generated multiple numbers per site.

In 2006, 9 areas had between 24 and 67 confirmed 

samples per area, a season that lasted 31 weeks. In 2014, 

WNV was much more widespread than in any other of 

the 14 years. Although the virus was detected in 87.3% 

of the 268 areas and 1,286 mosquito pools were confirmed positive over a period of 18 weeks, there were 

only 34 areas with 10 or more confirmed pools during 

the season. Each of the remaining areas had fewer than 

10 confirmed WNV positive mosquito pools.

References

1. Hayes CG. West Nile Fever. In: Monath TP, ed. 

The Arboviruses: Epidemiology and Ecology. Vol. 

5. Boca Raton, FL: CRC Press; 1989:59-88.

2. Nash D, Mostashari F, Fine A, et al. The outbreak 

of West Nile infection in the New York City area in 

1999. N Engl J Med. 2001;344:1807-1814.

3. Roehrig JT, Layton M, Smith P, Campbell GL, 

Nasci R, Lanciotti RS. The emergence of West 

Nile virus in North America: ecology, epidemiology, and surveillance. Curr Top Microbiol Immunol. 2002;267:223-240.

4. Murray KO, Mertens E, Despres P. West Nile virus 

and its emergence in the United States of America. 

Vet Res. 2010;41(6):67.

5. Lillibridge KM, Parsons R, Randle Y, et al. The 

2002 introduction of West Nile virus into Harris County, Texas, an area historically endemic 

for St. Louis encephalitis. Am J Trop Med Hyg. 

2004;70:676-681.

Figure 6. Map of Harris County, Texas, showing 235 areas (87.7%) with confirmed WNV positive mosquito pools (1,286) in 2014. 

Positive areas are highlighted with red stripes and dots.
8 http://www.cs.amedd.army.mil/amedd_journal.aspx

6. Tsai, TF, Bolin RA, Montoya M, et al. Detection of 

St. Louis encephalitis virus antigen in mosquitoes 

by capture enzyme immunoassay. J Clin Microbiol. 

1987;25(2):370-376.

7. Burkhalter KL, Lindsay R, Anderson R, Dibernardo A, Fong W, Nasci RS. Evaluation of Commercial Assays for Detecting West Nile Virus Antigen. 

J Am Mosq Contr Assoc. 2006;22:64-69.

8. Kesavaraju B, Farajollahi A, Lampman RL, et al. 

Evaluation of a rapid analyte measurement platform for West Nile virus detection based on United 

States mosquito control programs. Am J Trop Med 

Hyg. 2012;87:359-363.

9. Burkhalter KL, Horiuchi K, Biggerstaff BJ, Savage 

HM, Nasci RS. Evaluation of a rapid analyte measurement platform and real time reverse transcriptase polymerase chain reaction assay West Nile virus detection system in mosquito pools. J Am Mosq 

Contr Assoc. 2014;30(1):21-30.

10. Tesh RB, Parsons, R, Siirin M, et al. Year-round 

West Nile Virus Activity, Gulf Coast Region, Texas 

and Louisiana. Emerg Infect Dis. 2004;10(9):1649-

1652. Available at: http://www.ncbi.nlm.nih.gov/

pmc/articles/PMC3320313/.

Authors

Ms Randle is a retired former virologist with the Mosquito Control Division, Harris County Public Health, 

Houston, Texas.

Ms Freeman is a Virolgist with the Mosquito Control 

Division, Harris County Public Health, Houston, Texas.

Ms Jackson is a Virological Specialist I with the Mosquito Control Division, Harris County Public Health, 

Houston, Texas.

Mr Reyna is the Technical Operations Manager of the 

Mosquito Control Division, Harris County Public Health, 

Houston, Texas.

Dr Debboun is the Director of the Mosquito Control Division, Harris County Public Health, Houston, Texas.

2014: A Record-Breaking Year for West Nile Virus Positive Mosquito Pools

in Harris County and the City of Houston, Texas

Figure 7. Map of Harris County, Texas, showing 138 areas (51.5%) with confirmed WNV positive mosquito pools (406) in 2015. Positive areas are highlighted with red stripes and dots.

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Sources: Esri, HERE, DeLorme, TomTom, Intermap, increment P Corp., GEBCO, USGS, FAO, NPS,

NRCAN, GeoBase, IGN, Kadaster NL, Ordnance Survey, Esri Japan, METI, Esri China (Hong Kong),

swisstopo, MapmyIndia, © OpenStreetMap contributors, and the GIS User Community C. Fredregill

¢[ WNV Positive Dead Birds (14)

!H New WNV Positive Pools (1)

!H WNV Positive Pools (405)

WNV Positive Areas (139)

3

This map is intended solely for internal use amongst employees of HCPHES Mosquito

Control. Information contained within this map is sensitive and subject to change.

1 inch equals 7 miles

0 5 10 20 Miles

Mosquito-Borne Disease Activity 2015

Updated:

11/25/2015
October – December 2016 9

Richmond County is located on the Georgia/South Carolina border, about 150 miles (240 km) east of Atlanta 

and 70 miles (110 km) west of Columbia. According to 

the US Census Bureau (2015), the county has a total 

area of 329 square miles; 324 square miles is land and 

4.3 square miles (1.3%) is water.Richmond County is in 

the Savannah River basin.1

Augusta is the principal city of the Augusta-Richmond 

County Metropolitan Statistical Area, which as of 2012 

had an estimated population of 580,270,1

 making it the 

third-largest city and the second-largest metro area in 

the state after Atlanta. Augusta is located about halfway 

up the Savannah River on the fall line, which creates a 

number of small falls on the river. The city marks the 

end of a navigable waterway for the river and the entry 

to the Georgia Piedmont area.

The Richmond County Mosquito Control program is a 

part of the Richmond County Environmental Health office. It is a small program with one full-time and 4 seasonal workers that was established in 1983 in response to the 

emergence of a large nuisance mosquito problem. Some 

limited surveillance was done in the county in response 

to West Nile virus (WNV), but the program worked to 

create partnerships with other county and local agencies, 

as well as with the Georgia Department of Public Health 

(GDPH), with the intent to expand the program into a 

fully functioning, integrated pest management operation. 

Some surveillance was done by the state entomologist in 

response to either complaints or WNV cases beginning 

in 2004. In 2007, the mosquito control program hired a 

seasonal mosquito surveillance technician for the year. 

Because of the benefits to the program associated with 

mosquito surveillance, in 2014 the Richmond County 

Mosquito Control program joined forces with the Phinizy Center for Water Sciences, a local nonprofit water 

quality research organization in order to trap mosquitoes 

at sites across the county and identify them to species. 

These data helped determine locations of disease-carrying mosquitoes during the 2015 WNV season, allowing 

mosquito control to prioritize their control efforts, reducing the risk of viral transmission in Richmond County.2

The GDPH supported these efforts with free mosquito 

identification and training classes for the researchers at 

Phinizy Swamp, as well as providing use of the GDPH 

emergency mosquito surveillance trailer with its complement of mosquito surveillance equipment.3

A Multiagency Approach to Reducing

 West Nile Virus Risk in Richmond County,

 Georgia, in 2015

Rosmarie Kelly, PhD, MPH

Fred Koehle

Oscar P. Flite III, PhD

R. Chris Rustin, DrPH, MS, REHS

Abstract

The Richmond County Mosquito Control program’s mission statement is to incorporate strategies of integrated 

mosquito control management that are effective, practical, and environmentally safe and protect the health of Richmond County residents, as well as promote public education, in order to prevent large mosquito populations and 

the diseases that they transmit. To this end, the program coordinates efforts with other county agencies in order to 

provide better service. This is a small program with limited resources, so in an effort to provide better integrated 

mosquito management, the mosquito control program and the Phinizy Center for Water Sciences joined efforts to 

trap mosquitoes at sites across the county, identify the species, and send the mosquitoes off for viral testing. These 

data help determine locations of disease-carrying mosquitoes so the county can more efficiently control the mosquito populations and reduce the risk of West Nile virus transmission.

The Phinizy Center for Water Sciences

The Phinizy Center for Water Sciences was established to provide leadership to balance sustainable watersheds 

and economic vitality through solutions-based research, education, and public involvement (http://phinizycenter.

org). The Phinizy Center manages the Phinizy Swamp Nature Park, a 1,100-acre nature park in the city of Augusta. 

The park contains wetlands and woodlands and has a campus for water research and environmental education. As 

the wetlands at Phinizy Swamp Nature Park obviously have the potential to contribute to mosquito problems in 

Richmond County, the scientists at the Phinizy Center are intimately involved in efforts to address the risks.
10 http://www.cs.amedd.army.mil/amedd_journal.aspx

West Nile virus is a mosquito-borne viral pathogen that 

was introduced into the United States in 1999. Within 4 

years following its initial detection in New York, WNV 

was detected in states from the East and West coasts as 

well as in Mexico and Canada.4

West Nile virus is maintained in birds. It occasionally 

infects humans who are bitten by mosquitoes that have 

been feeding on birds. Most people (approximately 

80%) infected with WNV do not develop symptoms. 

About one in five infected people experiences a milder 

illness, often termed “West 

Nile fever,” characterized 

by fever, headache, muscle 

weakness or myalgia, arthralgia, and sometimes 

rash. Less than one percent 

of persons infected with 

WNV develop neurologic 

illness (West Nile neurologic disease (WNND)) 

in the form of meningitis, 

encephalitis, or possibly 

acute flaccid paralysis. Approximately 3% to 15% 

of WNND cases are fatal. 

Risk of WNND is associated with increasing age and 

the presence of underlying 

medical conditions.

The presence of WNV in 

Georgia was first confirmed in July 2001 when 

an American crow from Lowndes County tested positive for the virus. Since then, human cases, equine cases, 

positive birds, and positive mosquito pools have been 

detected every year within the state.

Since 2012, human cases have been reported every year 

in Richmond County (Table 1). Since mosquito control 

is a small program, it was determined that an interagency approach was needed to better target mosquito 

control to reduce mosquito populations and reduce the 

risk of WNV transmission. High risk areas are defined 

as areas with a human WNV case or a WNV positive 

mosquito pool.

Methods

In 2015, Richmond County Mosquito Control created a 

5-step action plan for responding to a potential WNV 

outbreak:

Step 1: Identify a 2-block area on all sides of the high 

risk area without identifying case location (Figures 1 

and 2). For human cases, the street name is obtained 

from the GDPH District Epidemiologist. (Note: The 

state of Georgia is divided into 18 public health districts of varying size based on population.)

Step 2: Mosquito surveillance and identification is 

provided by the Center for Water Science at Phinizy Swamp. When a WNV positive case is detected, 

trapping equipment will be positioned to establish 2 

locations on each side of the positive site. Traps will 

be set every 2 weeks, and selected species will be 

sent for virus testing after identification. This will 

continue until the end of the year.

Step 3: Realign the spray areas to include WNV positive locations. Use a thermal fogger in overgrown 

yards and unoccupied houses. If any mosquito pools 

test positive for WNV, reevaluate the spray areas and 

patterns. Add an additional spray event in the early 

morning to control daytime biters (Table 2).

Step 4: Conduct a neighborhood survey (Figure 3) to 

locate any other mosquito habitats that can be eliminated or treated, working with code enforcement, animal control officers, and deputies from the marshalls’ 

department to write citations if necessary. Once completed, reevaluate the spray areas with any new information and make any necessary adjustments.

Step 5: Continue the public awareness program. This 

includes media events, health fairs, and a family 

emergency planning day.

The non-WNV positive areas continued to be sprayed as 

needed and were monitored for other complaints. Surveillance in these areas is done every 2 weeks.

A Multiagency Approach to Reducing West Nile Virus Risk

in Richmond County, Georgia, in 2015

Table 1. Human Cases of 

WNV: Georgia statewide and 

Richmond County, 2001-

2015*

Year Georgia

Statewide

Richmond

County

2001 6

2002 36

2003 55

2004 23 2

2005 24 1

2006 11

2007 55 3

2008 12

2009 6

2010 14

2011 25

2012 117 4

2013 20 1

2014 13 2

2015 15 3

*Data from GDPH Arboviral Surveillance and Richmond County Mosquito Control records.

Table 2. Spray and Trapping Schedule

Date Procedure

8/25/2015 First morning spray (7:45 to 8:45)

8/27/2015 Evening spray (6:30 to 7:30)

8/31/2015 Baseline trapping at 4 selected sites

9/1/2015 Morning spray

9/3/2015 Evening spray

9/4/2015 Mosquito pools from baseline sent for testing*

9/8/2015 Morning spray

9/10/2015 Evening spray

9/15/2015 Morning spray

9/15/2015 First trapping of regular series (every 2 weeks)

9/17/2015 Evening spray

9/17/2015 Mosquito pools from regular series sent for testing*

9/22/2015 Morning spraying cancelled due to rain

9/24/2015 Evening spray

*Virus testing conducted by University of Georgia College of Veterinary 

Medicine as part of the Southeastern Cooperative Wildlife Disease 

Study (http://vet.uga.edu/scwds).
October – December 2016 11

The Army Medical Department Journal

Results

Typically, Richmond County has very few WNV human cases. The first human case was reported in 2004; 

the first case in Georgia was reported in 2001. However, 

since 2012, there have been cases reported every year 

in Richmond County. Mosquito surveillance had been a 

missing component of the Richmond County Mosquito 

Control Program. The creation of a partnership with the Phinizy Center for Water 

Sciences has resulted in better focused mosquito control efforts. In 2015, the first WNV 

case in Richmond County was reported in 

July, and a second case reported soon after. A third case was reported the following 

month. All 3 cases were less than 10 miles 

from one another. Culex quinquefasciatus, 

Georgia’s primary WNV vector, flies approximately a half mile in search of a blood 

meal. In an effort to reduce the risk of WNV 

in the area between and around the 3 case 

sites, Richmond County Mosquito Control 

implemented their 5-step response program.

The 2015 area surveillance in the high risk 

area (Figure 2) collected 12 different mosquito species, including Culex quinquefasciatus (Table 3). Twenty-five mosquitoes 

sampled from one pool tested positive for 

WNV (Table 4). Although the number of 

WNV cases in Richmond County has historically not been high, the ability to better 

target mosquito control has helped reduce 

risk of disease transmission.

Conclusions

Although complaints by residents can provide some information on the presence of 

mosquito problems in a given area, surveillance allows the targeting of areas where 

vector populations are high. Surveillance 

and viral testing also provides a means of 

determining the effectiveness of control efforts. Although some level of surveillance 

was done in Richmond County almost every year starting in 2004, it was primarily performed once a month. More frequent 

surveillance is needed to support targeted 

mosquito control efforts.

The collaboration with the Phinizy Center 

has changed mosquito control operations 

and saved Richmond County money. Identifying areas of the county with diseasecarrying species helps to accomplish the 

primary mission of aiding public health by reducing the 

number of vector species and reducing the risk of disease transmission.

The current goal is to increase public education programs with civic clubs, churches, schools, homeowners’ 

associations, and public events. Outreach to the public 

Figure 1. Map of Richmond County, Georgia, showing the high risk area of 

concern.

Figure 2. Area specifically treated following neighborhood survey.
12 http://www.cs.amedd.army.mil/amedd_journal.aspx

A Multiagency Approach to Reducing West Nile Virus Risk

in Richmond County, Georgia, in 2015

Date and time: October 20, 2015 10 am to 3 pm

People involved:

• 5 from Mosquito Control

• 1 from Environmental Health as observer

• 1 from Center for Water Sciences (trapping and 

identification)

• 5 from Augusta/Richmond County Code Enforcement

• 3 from Richmond County Marshal’s department

• 6 from Richmond County Sheriff’s department

• Animal control was on standby due to personnel shortage.

142 Properties surveyed (Figures 1, 2):

• 32 houses on Bandler Rd

• 49 houses on Circular Dr

• 15 houses on Harold Dr

• 17 houses on Sanders Rd

• 26 houses on Martin Rd

• 3 houses on Ivey Rd

Age of houses in survey area:

• 80% of the houses in the survey area were built between 

1944 and 1952.

• All houses are located within a 180-acre area divided 

equally on both sides of a major 4 lane highway.

• All houses on both sides are similar in age and 

maintenance.

• Construction materials range from brick to lap board and 

T-11. Most carports are aluminum.

• Almost all houses have crawl spaces which are well known 

as mosquito habitats.

Figure 3. Neighborhood survey following surveillance and treatment of 

area of concern.

Table 3. Mosquito Surveillance Data From a High Risk Area

Species 08/31/15 09/02/15 09/09/15 09/23/15 10/14/15 Species

Total

Aedes albopictus 115 113 88 98 65 479

Aedes vexans 1 16 2 19

Anopheles crucians 

complex

4 4

Anopheles 

quadrimaculatus

2 2 13 4 21

Culex erraticus 27 2 29

Culex nigripalpus 1 2 3

Culex 

quinquefasciatus

6 19 2 147 38 212

Culex salinarius 69 30 3 779 881

Ochlerotatus 

triseriatus

1 4 3 8 16

Orthopodomyia 

signifera

2 2

Psorophora 

columbiae

1 2 2 5

Psorophora ferox 1 1

Grand Total 122 236 139 275 900 1,672

Table 4. Richmond County Mosquito Surveillance Results, 2004-2015

Year WNV Test Results Yearly

Negative Positive Total

2004 17 17

2006 373 373

2007 1,395 7 1,402

2008 1,906 1,906

2009 841 841

2010 212 212

2011 384 384

2012 4,992 4,992

2013 2,272 2,272

2014 111 111

2015 747 25 772

Grand

Total

13,250 32 13,282
October – December 2016 13

The Army Medical Department Journal

is the best method of reducing mosquito habitats for the 

better health of the citizens of Richmond County, especially with the recently identified potential risks presented by the Zika virus.

References

1. US Census Bureau. Quick Facts; Richmond County, Georgia. US Census Bureau website. Available at: https://www.census.gov/quickfacts/table/

PST045215/00,13245. Accessed May 31, 2016.

2. Mirshak M. Phinizy Center, Richmond County 

Mosquito Control join efforts to identify mosquito 

species [internet]. The Augusta Chronicle. August 

9, 2015. Available at: http://chronicle.augusta.com/

news/metro/2015-08-09/phinizy-center-richmondcounty-mosquito-control-join-efforts-identifymosquito#. Accessed May 31, 2016.

3. Georgia Mosquito Control Association. Georgia 

Emergency Surveillance Trailer Protocols. Georgia 

Mosquito Control Association Website. Available 

at: http://www.gamosquito.org/resources/Georgia

EmergencyMosquitoSurveillanceTrailerUseProto

cols.pdf. Accessed May 31, 2016.

4. Centers for Disease Control and Prevention. West 

Nile virus [internet]. CDC website. Available at: 

http://www.cdc.gov/westnile/. Accessed May 31, 

2016.

Authors

Dr Kelly is a Public Health Entomologist with the VectorBorne & Zoonotic Diseases Team Environmental Health 

Section, Georgia Department of Public Health, Atlanta, 

Georgia.

Mr Koehle is with the Environmental Health Section of 

the Richmond County Department of Public Health, Augusta, Georgia.

Dr Flite is the Chief Executive Officer and Senior Scientist, Phinizy Center for Water Sciences, Augusta, 

Georgia.

Dr Rustin is with the Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, 

Georgia.

Articles published in the Army Medical Department Journal are 

indexed in MEDLINE, the National Library of Medicine’s (NLM’s) 

bibliographic database of life sciences and biomedical information. 

Inclusion in the MEDLINE database ensures that citations to AMEDD 

Journal content will be identified to researchers during searches for 

relevant information using any of several bibliographic search tools, 

including the NLM’s PubMed service.
14 http://www.cs.amedd.army.mil/amedd_journal.aspx

The role of the Royal Australian Army Medical Corps 

and the US Army Medical Department is to provide the 

best medical care for members of the Australian and 

US armed forces. The task to provide protection against 

vector-borne diseases such as malaria, dengue, arboviruses, and others is undertaken by various groups in 

both countries. In Australia, this work has been undertaken by a small group of medical officers and scientists 

at the Army Malaria Research Unit (AMRU), which became the Army Malaria Institute (AMI),1-6 and in the 

United States, the Walter Reed Army Institute of Research (WRAIR) in Forest Glen, MD, and its overseas 

laboratories.7

Collaboration between the United States and Australia 

was important during World War II in the Pacific. The 

work conducted between 1941 and 1945 by the Australian Land Headquarters Medical Research Unit is described in detail by LTC A. W. Sweeney in his book, 

Malaria Frontline.

8

During the Vietnam War, many cases of vector-borne 

disease were observed in Australian, United States, and 

other Allied defense personnel. The medical resources 

and personnel of both countries collaborated to optimize 

and evaluate measures against diseases. The high number of malaria cases in Australian soldiers in Vietnam 

in 1965 resulted in the establishment in 1966 of the 1 

Malaria Research Unit, under the direction of Professor 

Robert H. Black at the University of Sydney. This unit 

was moved to Ingleburn, 35 km southwest of Sydney, 

New South Wales, in 1974.1

In 1985, LTC Sweeney visited medical research units in 

the United States and fostered a formal collaboration between AMRU and US military scientists. One of the first 

collaborations involved field testing of new mosquito repellents and permethrin treated military uniforms at Cowley Beach, northern Queensland, Australia. This field trial 

was conducted by 4 scientists from the Letterman Army 

Institute of Research, Presidio of San Francisco, and 

AMRU. The study showed that a combination of wearing 

permethrin treated battle dress uniforms and repellents 

containing deet provided the best protection against mosquitoes.9

 A subsequent field trial at the same site in 1990 

conducted by AMRU and the US Department of Agriculture compared methods of protection against trombiculid larvae (chiggers). This study showed that permethrin 

treated uniforms provided protection against mites that 

cause scrub itch.10

Protection of Military Personnel Against

 Vector-Borne Diseases: A Review of

 Collaborative Work of the Australian

 and US Military Over the Last 30 Years

Stephen P. Frances, PhD Mustapha Debboun, PhD, BCE

Michael D. Edstein, PhD G. Dennis Shanks, MD

Abstract

Australian and US military medical services have collaborated since World War II to minimize vector-borne 

diseases such as malaria, dengue, and scrub typhus. In this review, collaboration over the last 30 years is 

discussed. The collaborative projects and exchange scientist programs have resulted in mutually beneficial 

outcomes in the fields of drug development and personal protection measures against vector-borne diseases.

LT Doug Waterhouse, Royal Australian Army Medical Corps, 

conducting mosquito repellent tests at Lalipipi village in Papua 

New Guinea during World War II (1943).

Mention of a commercial product does not constitute an endorsement of the product by the Australian Defence Force or US Department of Defense.
October – December 2016 15

The Army Medical Department Journal

Exchange Scientists

Medical Officers in Malaysia

Australian medical officers first worked in Malaysia 

at the US section of the Institute of Medical Research 

(IMR) in Kuala Lumpur in the early 1980s. They collaborated with US Army and Malaysian medical officers 

on protection against scrub typhus and snake envenomation. The joint studies conducted showed that doxycycline was an effective prophylaxis for scrub typhus,11

and field surveillance showed that disease in Malaysia 

was underreported.12,13

Exchange Scientists in Thailand and Australia

In 1988, the US section of IMR Malaysia closed and an 

exchange was established with the Armed Forces Research Institute for Medical Sciences (AFRIMS) in Bangkok, Thailand, and the Australian AMRU. Between 1989 

and 1992, MAJ M. D. Edstein from AMRU worked at 

AFRIMS primarily on preclinical drug development and 

clinical evaluation of standard and new antimalarial drugs. 

During this 3-year period, MAJ Edstein and US Army 

and Thai Army collaborators researched new antimalarial compounds using nonhuman primates for causal prophylactic and radical curative activity. Of these studies, 

WR182393, a non-8-aminoquinoline guanylhydrazone, 

exhibited both causal prophylactic and radical curative properties in the rhesus monkey (Macaca mulatta)/

Plasmodium cynomolgi test model, a vivax malaria-like 

model.14 However, using the same model, the prophylactic combination of proguanil plus sulfamethoxazole was 

found not to be causally prophylactic.15 Additionally, the 

proguanil analog WR250417 (also known as PS-15) was 

shown to extend the prepatent period of P cynomolgi

from 8.5 days to 18.3 days in drug-treated monkeys, but 

did not prevent a primary infection.16

For clinical studies, new high performance liquid chromatographic (HPLC) methods were developed for the 

analysis of antimalarial drugs such as quinine,17 halofantrine,18 mefloquine-sulfadoxine-pyrimethamine,19 and 

ciprofloxacin.20 These HPLC methods were used to characterize the pharmacokinetic-pharmacodynamic interaction of mefloquine in resistant P falciparum malaria on 

the Thai-Burma/Myanmar* border,21 assess the efficacy 

of halofantrine in treating Thai patients who failed mefloquine chemoprophylaxis,22 evaluate the potential of ciprofloxacin in treating drug-resistant falciparum malaria,23

assess the effect of food on the disposition of halofantrine 

in treating falciparum malaria24 and determine the effectiveness of high-dose mefloquine in treating multidrugresistant falciparum malaria.25

At the time of those studies, mefloquine was the treatment of choice for uncomplicated multiresistant falciparum malaria. A standard dose of 15 mg/kg of mefloquine became ineffective in treating acute falciparum 

malaria in an area with deteriorating multidrug resistance on the Thai-Myanmar border. By increasing the 

mefloquine dose to 25 mg/kg, the clinical and parasitologic responses were significantly more rapid with high 

dose mefloquine compared with the standard dose.26

The failure rate by day 28 of follow-up was 40% and 9% 

with 15 mg/kg and 25 mg/kg of mefloquine respectively. 

Adverse events were dose-related and included dizziness, anorexia, nausea, vomiting, and fatigue.

Mefloquine in combination with sulfadoxine and pyrimethamine (MSP) at a single dose of 15/30/1.5 mg/kg, 

respectively, also became ineffective. In 1985-1986, MSP 

cured over 98% of 5,192 patients with falciparum malaria on the Thai-Myanmar border. Four years later, the 

efficacy of MSP in 395 patients at the same location had 

declined to 71%. In these patients, the mean serum mefloquine concentration at the time of first recrudescence 

was 638 (546-730) ng/mL, a value previously associated 

with successful treatment. These findings suggested 

that P falciparum had rapidly developed resistance to 

mefloquine, despite the addition of sulfadoxine and 

pyrimethamine. The recommendation was to abandon 

the MSP combination.21 The development of resistance 

to mefloquine highlighted the urgent need to evaluate 

new antimalarial drugs such as halofantrine. The recommended regimen of halofantrine was 3 doses of 500 mg 

MAJ Michael Edstein of the AFRIMS Department of Immunology 

(on assignment from the Australian Army Malaria Institute), and 

MAJ Catherine (Dahlem) Smith, US Army, Chief of the Department of Veterinary Medicine, team up to administer an antimalarial drug to a monkey in a pharmacokinetic study (1990). 

Photo courtesy of AFRIMS photograph archives.

*The country of Burma was renamed Myanmar in 1989.
16 http://www.cs.amedd.army.mil/amedd_journal.aspx

(1,500 mg total or 24 mg/kg) at 6-hour intervals 

given with food to enhance drug absorption. 

However, this halofantrine regimen was found 

to be ineffective in treating 30% (7/23) of Thai 

soldiers who showed slide-positive results for 

malaria while receiving mefloquine chemoprophylaxis.22 The serum halofantrine concentrations were higher in patients cured by halofantrine compared with those who failed treatment. 

These observations suggested that the 24 mg/

kg regimen of halofantrine was not optimal for 

the treatment of multiple drug-resistant falciparum malaria in Thailand. A higher dose of 

halofantrine (72 mg/kg) was more effective in 

treating uncomplicated falciparum malaria with 

a failure rate of 15%, but evidence of possible 

cardiotoxicity was observed and required investigation.26 Studies by other investigators led to 

the demise of halofantrine due to cardiotoxicity.

In 1992, MAJ Edstein was replaced at AFRIMS by MAJ S. P. Frances, an entomologist, 

who worked on personal protection measures 

against malaria vectors, and biology of the vectors of scrub typhus. While at AFRIMS, Frances conducted laboratory and field evaluations 

of repellents and toxicants against mosquito 

vectors of malaria and mite vectors of Orientia tsutsugamushi.

27-33 He also worked on vectors of scrub typhus, resulting in the establishment of colonies of Leptotrombidiun deliense

(mites) naturally infected with O tsutsugamushi, and improved understanding of the ecology 

of mites, rodent hosts, and the pathogen that 

causes scrub typhus in Thailand.34-44

During the same time (1992-1995), LTC G. 

D. Shanks worked at AMRU in Australia. He 

worked closely with MAJ Edstein, who had 

returned to Australia, on development of antimalarial drugs. A number of valuable findings 

during this time included several clinical trials 

in Papua New Guinea.45-48

Collaborative Projects

Collaboration between AMI and US military scientists 

has continued. In the 1990s, evaluation of repellent active ingredients deet, AI3-37220, and CIC4,* along with 

personal protection measures against mosquitoes was 

undertaken. In 2001, an evaluation of Australian and 

US repellents was conducted in Australia at Cowley 

Beach by the AMI with US Army MAJ M. Debboun 

from WRAIR. The study compared the protection provided by commercial and military repellent on human 

volunteers.49 This collaboration continued with evaluation of additional active ingredients in the laboratory 

and field,50 as well as field evaluation of a low profile US 

bednet in Papua New Guinea.51 The prototype bednet 

that was tested has been in use by US military personnel for more than a decade.52 More recently, 3 books on 

repellents and personal protection measures used by civilian and military personnel were edited by US Army 

and Australian Defence Forces entomologists.53-55

MAJ Stephen Frances (ADF) treating Royal Thai Army uniforms with permethrin from a back pack aspirator in Sisaket Province, Thailand, 1992.

MAJ Stephen Frances (AMI), Dr Nigel Beebe (University of Technology 

Sydney, Australia), MAJ Mustapha Debboun (WRAIR) and Senior COL 

Nguyen van Dung (Vietnam Peoples Army), at Cowley Beach Training Area, 

northern Queensland, Australia, during mosquito repellent trials in 2001.

*deet (diethylmethyl benzamide); AI3-37220 (1-(3-cyclohexen1-cabonyl)-2-methylpiperidine); CIC-4 (2-hydroxomethylcyclohexl) 

acetic acid)

Protection of Military Personnel Against Vector-Borne Diseases: A Review of

Collaborative Work of the Australian and US Military Over the Last 30 Years
October – December 2016 17

The Army Medical Department Journal

Financial support from the Defence Warfighters Program of the Armed Forces Pest Management Board to AMI in 2008, allowed evaluation 

of Australian military shirt fabrics treated with 

permethrin to be tested to determine protection 

against mosquito bites of malaria and dengue 

vectors.56,57

Drug Development

The development of mefloquine as an antimalarial drug was reviewed by Shanks.58 The 

constraints of shrinking military and civilian 

budgets for development of antimalarial drugs 

highlighted the need to continue to conduct 

collaborative development of drugs. Despite 

this, collaborative research to develop new antimalarial drugs between the two nations has 

continued.

From 1998-2011, exchange scientists from WRAIR 

undertook collaborative evaluation of the new antimalarial drug tafenoquine (formerly known as WR238605 

or etaquine) for malaria prevention and in vitro studies into artemisinin induced dormant ring-stages of P 

falciparum as a plausible explanation for recrudescence. 

In 1998, a field study of tafenoquine was conducted in 

Ubon Ratchatani province, Thailand, with Thai soldiers 

and collaborators from Australia, United States, and 

Thai military.59 The major focus of the study was to determine the safety, tolerability, efficacy, and pharmacokinetics of tafenoquine following an oral loading dose 

of 400 mg daily for 3 days and monthly administration 

of 400 mg for 5 consecutive months.59 In participants 

completing the follow-up period (96 tafenoquine and 

91 placebo recipients), there were 22 P vivax, 8 P falciparum, and one mixed infection. With the exception of 

one P vivax infection in the tafenoquine group, all infections occurred in placebo recipients, giving tafenoquine 

a protective efficacy of 97% for all malaria, 96% for P 

vivax malaria, and 100% for P falciparum malaria. The 

soldier in the tafenoquine group who developed malaria 

during the study had a lower plasma tafenoquine concentration of 40 ng/mL at the time of diagnosis, which 

was approximately 3-fold lower than the trough concentrations of the other soldiers who were protected from 

infection by tafenoquine.60 The phase II study revealed 

that monthly tafenoquine was safe, well tolerated, and 

highly effective in preventing P vivax and multidrugresistant P falciparum malaria in Thai soldiers during 6 

months of prophylaxis. This study was the first investigation of tafenoquine in Southeast Asia and in protecting 

volunteers from both P vivax and P falciparum malaria.

To assist in the development and evaluation of tafenoquine, a rapid and sensitive HPLC method for tafenoquine was developed by CPT D. A. Koscisko, US 

Army, during his assignment to AMI from 1999-2001. 

With this method, the population pharmacokinetics of 

tafenoquine was characterized in Thai soldiers who participated in the phase II study.61,62 A one-compartment 

model was found best to describe the pharmacokinetics 

of tafenoquine after oral administration. The drug is 

widely distributed to body tissues with a high apparent volume of distribution and a lengthy elimination 

half-life of 16.4 days, suitable for weekly prophylaxis.

LTC D. E. Kyle, US Army, established the WRAIR 

laboratory at AMI in 2001. He collaborated in studies 

of the drug Artimisone, which showed it was more 

effective than artemisinin drugs in curing P falciparum in Aotus monkeys.6,63,64 He has continued collaboration with AMI in his role as a professor at South 

Florida University with studies of the role of gene amplification and expression that induces resistance in P 

falciparum.

65-68

LTC Pamornwan Singsawat, Royal Thai Army, and LTC Douglas 

Walsh (AFRIMS) interview potential subjects in a joint malaria 

prophylaxis drug study among Thai soldiers in Ubon Ratchathani 

(1998). Photo courtesy of AFRIMS photograph archives.

Low profile bednet developed at WRAIR and tested in Bougainville, Papua 

New Guinea, in 1999.
18 http://www.cs.amedd.army.mil/amedd_journal.aspx

In February 2004, LTC Kyle returned to the United 

States and was replaced at AMI by MAJ Mike O’Neil. 

From 2004 to 2006, he participated in the assessment 

of the pharmacodynamics and pharmacokinetics of the 

novel dihydrofolate reductase inhibitor, JPC2056, and 

its principal active metabolite JPC2067 in cynomolgus 

monkeys using an in vivo-in vitro (ex vivo) model.69 In 

a 2-phase crossover design, cynomolgus monkeys were 

administered multiple doses (20 mg/kg daily for 3 days) 

of JPC2056. Plasma samples collected from treated 

monkeys were assessed for ex vivo antimalarial activity against P falciparum lines having wild-type (D6), 

double-mutant (K1) and quadruple-mutant (TM90-

C2A) DHFR-thymidylate synthase (TS) and a P falciparum line transformed with a P vivax dhfr-ts quadruple-mutant allele (D6-PvDHFR). Plasma JPC2056 and 

JPC2067 concentrations were measured by LC-mass 

spectrometry. The mean inhibitory dilution (ID90) of 

monkey plasma at 3 hours after the last dose against D6, 

K1, and TM90-C2A was 1613, 1120, and 1396, respectively. Less activity was observed with the same monkey plasma samples against the D6-PvDHFR line, with 

a mean ID90 of 53. Geometric mean plasma concentrations of JPC2056 and JPC2067 at 3 hours after the last 

dose were 150 and 17 ng/mL, respectively. The elimination half-life of JPC2056 was shorter than its metabolite 

after both regimens (6.6 versus 11.1 hours). The high ex 

vivo potency of JPC2056 against P falciparum DHFRTS quadruple-mutant lines provides optimism for the 

future development of JPC2056 as a therapeutic agent.

In 2006, LTC N. Waters (US Army) was assigned to the 

WRAIR laboratory at AMI. He participated in a major 

AMI activity and Australian Government Pacific Malaria 

Initiative assisting in malaria eradication efforts in the 

Solomon Islands and Vanuatu.70 The Drug Resistance and 

Diagnostics department of AMI collaborated with LTC 

Waters on studies of the molecular assessment of parasite 

drug resistance.71 They found that P falciparum from both 

Solomon Islands and Vanuatu had high levels of resistance to Chloroquine 72 and Fansidar.73 LTC Waters was 

next assigned to the US Military Academy, West Point, 

NY, in 2011, and has brought cadets to Australia each year 

from 2011-2015 to work in the AMI laboratories.

The Future

After more than 20 years of having US Army officers 

working in Australia at AMI, the exchange program 

has lapsed due to nonavailability of those officers. However, the collaboration between the 2 countries continues, especially in the fields of entomological research, 

drug development, and pharmacology. With the continued meager funding of some fields of medical research 

and different priorities within the US and Australian 

Defence Forces, continued collaboration is important to 

continue to conduct valuable research on a variety of 

vector-borne diseases. The effect of malaria, dengue, 

and scrub typhus have remained focal for both countries, and collaborative research will continue to minimize the impact of these diseases on military personnel 

and civilians alike.

Acknowledgments

We thank Mrs Oranuch, AFRIMS, Bangkok, Thailand, for 

allowing us to use archival photos from AFRIMS collection. Studies reviewed in this paper were supported by a 

number of funding agencies, and we thank them for their 

support of both the Australian Defence Force and the US 

Department of Defense. The opinions expressed herein 

are those of the authors and do not reflect those of the 

Joint Health Command (Australia) or any Defence policy.

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64. Obaldia N 3rd, Kotecka BM, Edstein MD, et al. 

Evaluation of artemisone combinations in Aotus

monkeys infected with Plasmodium falciparum. Antimicrob Agents Chemother. 2009;53(8):3592-3594.

65. Chen N, Chavchich M, Peters JM, et al. Deamplification of pfmdr1-containing amplicon on chromosome 5 in Plasmodium falciparum is associated 

with reduced resistance to artelinic acid in vitro. Antimicrob Agents Chemother. 2010; 54(8):3395-3401.

66. Chavchich M, Gerena L, Peters J, et al. Role of 

pfmdr1 amplification and expression in induction 

of resistance to artemisinin derivatives in Plasmodium falciparum. Antimicrob Agents Chemother. 

2010;54(6):2455-2464.

67. Teuscher F, Gatton ML, Chen N, et al. Artemisinin-induced dormancy in plasmodium falciparum: 

duration, recovery rates, and implications in treatment failure. J Infect Dis. 2010;202(9):1362-1368.

68. Teuscher F, Chen N, Kyle DE, Gatton ML, Cheng 

Q. Phenotypic changes in artemisinin-resistant Plasmodium falciparum lines in vitro: evidence for decreased sensitivity to dormancy and 

growth inhibition. Antimicrob Agents Chemother. 

2011;56(1):428-431.

69. Edstein MD, Kotecka BM, Ager AL, et al. Antimalarial pharmacodynamics and pharmacokinetics of 

a third-generation antifolate--JPC2056--in cynomolgus monkeys using an in vivo in vitro model. J 

Antimicrob Chemother. 2007;60(4):811-818.

70. Harris I, Sharrock WW, Bain LM, et al. A large 

proportion of asymptomatic Plasmodium infections 

with low and sub-microscopic parasite densities in 

the low transmission setting of Temotu Province, 

Solomon Islands: challenges for malaria diagnostics 

in an elimination setting. Malar J. 2010;9:254. doi: 

10.1186/1475-2875-9-254.

71. Shanks GD, MD Edstein, Q Cheng, et al. Army 

Malaria Institute – its evolution and achievements 

fifth decade: 2006-2015. J Mil Vet Hlth. 2016 24(1). 

Available at: http://jmvh.org/article/army-malariainstitute-its-evolution-and-achievements-fifth-de

cade-2006-2015/. Accessed May 24, 2016.

72. Gresty K, Gray KA, Bobogare A, et al. Genetic mutations in Plasmodium falciparum and Plasmodium

vivax dihyrofolate reductase (DHFR) and dihydropteroate synthase (DHPS) in Vanuatu and Solomon Islands prior to the introduction of artemisinin 

combination therapy. Malaria J. 2014:13:402.

73. Gresty K, Gray KA, Bobogare A, et al. Genetic 

mutations in pfcrt and pfmdr1 at a time of the artemisinin combination therapy introduction in South 

Pacific islands of Vanuatu and Solomon Islands. 

Malaria J. 2014:13:406.

Authors

Dr Frances is with the Australian Army Malaria Institute, 

Enoggera, Queensland.

Dr Edstein is with the Australian Army Malaria Institute, 

Enoggera, Queensland.

Dr Debboun is the Director of the Mosquito Control Division, Harris County Public Health, Houston, Texas.

Dr Shanks is with the Australian Army Malaria Institute, 

Enoggera, Queensland. He is also a Professor at the University of Queensland School of Public Health, Brisbane, 

Australia.
22 http://www.cs.amedd.army.mil/amedd_journal.aspx

Rickettsiae and related ehrlichial organisms are obligate 

intracellular bacteria carried by mites, fleas, ticks, and 

lice and are the agents of numerous tick-borne diseases 

found in Virginia, such as Rocky Mountain spotted fever 

(Rickettsia rickettsii), Tidewater spotted fever (Rickettsia parkeri), Human monotropic ehrlichiosis (Ehrlichia 

chaffeensis), and Ewingii ehrlichiosis (Ehrlichia ewingii). These and other rickettsial diseases have affected 

military activities and public health throughout the 

world for more than 2,000 years.1

 Rickettsial diseases, 

generally incapacitating and sometimes fatal, are frequently unrecognized or misdiagnosed. If recognized 

early, they can be treated effectively with antibiotics 

such as doxycycline, the treatment of choice. Delayed 

treatment is often associated with a more serious disease outcome, often with complications.1

In the United States, there are many tick-borne rickettsiae, most of which belong to the spotted fever group 

of rickettsiae (SFGR). Among them are R rickettsii, R 

parkeri, Rickettisa montanensis, and Rickettsia amblyommii. The first two are known to be pathogenic to humans and the latter two have limited evidence suggesting possible pathogenicity.2

 Over the past few decades, 

rickettsiology has undergone significant changes and 

many new and some previously characterized rickettsiae have been found to be pathogenic.2,3 As of 2012, 26 

Rickettsia species with validated and published names 

have been reported, the vast majority of which are considered tick-borne rickettsiae.2

For most of the 20th century, R rickettsii, the causative 

agent of Rocky Mountain spotted fever, was considered 

the only tick-borne rickettsial agent pathogenic to humans in the Americas. Rocky Mountain spotted fever 

(RMSF) has been consistently described as a potentially 

fatal disease. In the early 20th century, 63% of RMSF 

diagnosed patients from Montana died from the disease.4

In the late 1940s, antimicrobial therapy was developed 

for RMSF4

 and doxycycline is now considered the drug 

of choice for all tick-borne rickettsial diseases in children and adults.5

 While the fatality rate of RMSF has 

diminished to 1.4% in the United States in the 21st century, it is higher in South American countries (greater 

than 20%) despite therapy.4,6 One of the reasons for the 

fatalities due to RMSF is the difficulty correctly diagnosing the rickettsiosis. Diagnosis of RMSF is problematic 

due to nonspecific signs and symptoms associated with 

the disease, which include fevers, headaches, rashes, and 

the lack of commercially available species-specific assays.2

 Recently there has been an increase in reported 

RMSF cases in the United States. Only 495 cases were 

reported to the Centers for Disease Control and Prevention (CDC) in 2000,7

 but 2,288 cases were reported in 

2006 and 2,016 in 2007, marking the highest recorded 

levels in over 80 years.8

 However, most of these cases 

Emerging Tick-borne Rickettsia and

Ehrlichia at Joint Base Langley-Eustis,

 Fort Eustis, Virginia

Melissa K. Miller, MS Holly Evans, PhD

Ju Jiang Timothy P. Christensen, MS

Melissa Truong Allen L. Richards, PhD

Tamasin Yarina

Abstract

Four species of ticks known to parasitize humans (Amblyomma americanum (lone star tick), Dermacentor variabilis (American dog tick), Amblyomma maculatum (Gulf Coast tick), and Ixodes scapularis (black-legged tick)) 

were collected at Joint Base Langley-Eustis, Fort Eustis, Virginia during 2009. These ticks were tested individually (adults and nymphs) and in pools of 15 (larvae) for pathogens of public health importance within the genera: 

Rickettsia, Borrelia, and Ehrlichia, by quantitative real-time polymerase chain reaction (qPCR) assays and, where 

appropriate, multilocus sequence typing (MLST). Of the 340 A americanum ticks tested, a minimum of 65 (19%), 

4 (1%), 4 (1%), and one (<1%) were positive for Rickettsia amblyommii, B lonestari, E ewingii and E chaffeensis, respectively. One of 2 (50%) A maculatum ticks collected was found to be positive for R parkeri by MLST 

and qPCR analyses. All 33 D variabilis ticks were negative for evidence of rickettsial infections. Likewise, no 

pathogenic organisms were detected from the single Ixodes scapularis tick collected. Pathogenic rickettsiae and 

ehrlichiae are likely emerging and cause under-recognized diseases, which threaten people who live, work, train, 

or otherwise engage in outdoor activities at, or in the vicinity of, Fort Eustis, Virginia.
October – December 2016 23

The Army Medical Department Journal

have been described as suspect RMSF cases (ie, clinical presentation and a single serum positive test which 

is group- but not species-specific). The prevalence of the 

SFGR antibody is known to exist in about 10% of the 

US population.9

 Thus, the presence of a single positive 

SFGR-specific serological assay will not specifically diagnose RMSF. Since the assay is nonspecific, the positive serologic reaction could represent an infection with 

another SFGR pathogen (eg, R parkeri, R akari) or a 

rickettsia of unknown pathogenicity (eg, R amblyommii, 

R montanensis). Thus, the lower fatality rates associated 

with RMSF may actually be due to the misdiagnosis of 

other rickettsioses with lower fatality rates than RMSF.

Tidewater spotted fever, also known as Rickettsia 

parkeri rickettsiosis or American boutoneuse fever, has 

been a recently described human disease even though 

the causative agent, R parkeri, has been known since 

its isolation in 1937. Ralph Robinson Parker isolated 

R parkeri from Amblyomma maculatum, commonly 

known as the Gulf Coast tick. R parkeri was considered 

a nonpathogenic rickettsia and received little attention 

until 2004, when the first case of R parkeri human infection, which was similar to yet distinct from RMSF, was 

reported.3,10 A second case of R parkeri human infection 

was documented 3 years later.11 Both cases were from 

the Tidewater region of Virginia, in the same region as 

Fort Eustis. New research has also revealed that multiple 

tick species within the Amblyomma genus can harbor 

R parkeri.

3,12 The many novel findings concerning R 

parkeri human infection indicate that much is still unknown about many human rickettsioses. Infection with 

R parkeri poses a significant threat to public health2

because at least one-third of reported RMSF cases are 

believed to be caused by R parkeri.

3,4

While R parkeri was newly identified as a pathogenic 

species, many other rickettsiae have emerged as possible 

pathogens, the most notable of which is R amblyommii. 

There have been tick bite rashes and probable RMSF 

cases associated with R amblyommii, though none have 

been confirmed.13,14 R amblyommii has been found in 

large percentages of Amblyomma americanum ticks, 

commonly known as lone star ticks, and is believed to 

be the most common rickettsia infecting A americanum

ticks.13,15-17 R amblyommii and Borrelia lonestari have 

been suspected at one time to play a role in southern 

tick-associated rash illness (STARI), however the true 

causative agent of STARI has yet to be confirmed.18-20

A americanum ticks are notoriously aggressive, nonspecific feeders whose geographic range covers a large portion of the continental United States.21-23 A confirmation 

that R amblyommii is a human pathogen would be of 

great interest and concern.

Other tick-borne obligate intracellular bacteria pathogenic to humans are E chaffeensis and E ewingii, members of the order Rickettsiales, and agents of human 

monocytotropic ehrlichiosis (HME) and ewingii ehrlichiosis, respectively.21 Human monocytotropic ehrlichiosis is a mild-to-fatal febrile illness with a case fatality rate of 2.7%.24 A majority of HME patients require 

hospitalization; in one HME study, 85% of patients were 

hospitalized and many had serious complications. Older patients were more likely to develop complications 

and have longer hospitalizations.25 Ehrlichia ewingii is 

known to cause a mild febrile illness in humans and may 

account for as much as 7% of all human ehrlichiosis cases in the United States.26 A americanum is the main vector of E chaffeensis and E ewingii, while whitetail deer 

(Odocoileus virginianus) are the preferred vertebrate 

hosts of A americanum.

21 Vertebrate hosts infected with 

ehrlichiae are bacteremic for prolonged periods,27 which 

increases the chance for transmission to a tick host. Human monocytotropic ehrlichiosis has been reported in 

47 states, with the highest reported average annual incidence rates in Arkansas, North Carolina, Missouri, and 

Oklahoma. Additionally, two-thirds of HME cases occur between May and July.24

Fort Eustis is an approximately 3,197 hectare military installation located in the Tidewater region of coastal Virginia. Over 2,100 hectares of this property are in natural 

areas including pine-mixed hardwood forests, wetlands, 

and early successional habitat. These natural areas provide abundant opportunities for military training and 

recreational activities like golfing, camping, hiking, and 

hunting. These types of activities often center around 

the warmer months when many tick species are at their 

most active. A large component of the overall force 

health protection plan on Fort Eustis involves familiarity with natural hazards such as vector-borne diseases, 

which may be transmitted to personnel by the bite of an 

infected tick. Because numerous tick-borne rickettsiae 

like R parkeri, the etiologic agent of Tidewater spotted 

fever, are emerging as pathogenic bacteria, evaluation of 

ticks in the Fort Eustis area of Virginia was undertaken 

to determine the risk of tick-borne disease to residents 

and visitors. A large-scale surveillance effort was begun 

in October of 2007 to assess the tick fauna of designated 

portions of the property. A concise but limited portion 

of this effort is presented here.

Materials and Methods

Specimens. Questing ticks were collected from 5 

preselected locations by dragging a one meter square 

cloth for approximately 100 meters at each site once per 

month from May through August 2009. Site selection 

was based on suitable tick habitat, and individual sites 
24 http://www.cs.amedd.army.mil/amedd_journal.aspx

were divided between areas of high human use such as 

golf course edges and walking trails, and low-human 

use such as gated natural areas. Additionally, the sites 

were not treated with any type of pesticide prior to or 

during this study.

Nucleic acid purification. Adult and nymph ticks were 

identified and individually placed in 300 μL of Tissue Lysis Buffer (Qiagen, Valencia, CA). Larvae were 

similarly handled with the exception that 15 larvae were 

placed in each 300 μL of lysis buffer. Ticks were bisected with a sterile knife and incubated with the addition of 

proteinase K prior to nucleic acid purification according 

to kit directions with the DNeasy Blood & Tissue Kit 

(Qiagen). Purified nucleic acids were eluted with 100 μL 

of elution buffer. The bisected ticks, remaining lysate, 

and purified nucleic acids were stored at -80°C for future analysis.

Polymerase chain reaction (PCR) and quantitative 

real-time PCR (qPCR) assays. Purified nucleic acid 

preparations from individual (adults and nymphs) and 

pooled (larvae; n=15) A americanum ticks were analyzed for R amblyommii by the Rambl qPCR assay as 

previously described.16 In addition, the A americanum

samples were screened for Ehrlichia species in a 20 μL 

real-time multiplex reaction designed to amplify and 

differentiate a segment of the heat shock protein operon 

groEL of E chaffeensis and E ewingii 28 using the LightCycler FastStart DNA Master HybProbe kit (Roche) and 

2 μL of sample. To be determined as positive, the sample melting peak was compared with a known standard 

and only samples that had an equivalent melting temperature were considered positive. Positive E ewingii

samples were confirmed to species in a 25 μL conventional PCR reaction targeting the p28 gene29 using the 

PuReTaq Ready-To-Go PCR Beads (GE Healthcare Biosciences, Piscataway, NJ) and 2 μL of sample. Samples 

positive for E chaffeensis were confirmed in a 20 μL 

qPCR reaction targeting the 16s rRNA sequence 30 using 

the LightCycler TaqMan Master kit (Roche) and 5 μL of 

sample. Borrelia lonestari infection was determined by 

screening with a SYBR Green I assay that amplified and 

detected a portion of the glpQ gene.31 Real-time PCR 

with a melting curve was performed in a 20 μL reaction 

using LightCycler SYBR Green I master mix (Roche) 

and 5 μL of sample. Samples that produced a melting 

peak and equivalent Tm to the known standard were 

further analyzed with a conventional PCR that amplified a portion of the flagellen gene of B lonestari.

32

Individual D variabilis, A maculatum, and pooled or individual A americanum nucleic acid preparations were 

screened for rickettsiae by the genus-specific Rick17b 

qPCR assay as previously described.33 The screen positive A maculatum nucleic acid preparation was assessed 

by the species-specific Rpark and Rande qPCR assays 

for R parkeri and Candidatus Rickettsia andeanae, as 

previously described.33 The single adult I scapularis

(black-legged tick) was tested for Borrelia and Anaplasma with a real-time multiplex34 using the LightCycler 

TaqMan Master Kit (Roche) in a 20 μL reaction with 5 

μL of sample. Conventional PCR was performed on a MJ 

Research PTC 200 Thermal Cycler (Bio-Rad Laboratories, Hercules, CA), and real-time PCR reactions were 

performed on the LightCycler 2.0 instrument (Roche).

Standard PCR for sequencing. Standard and nested 

PCR assays were used to amplify outer membrane protein B (ompB) and A (ompA), and the surface cell antigen 4 (sca4) genes of Rickettsia.

34 The master mix was 

composed of Platinum PCR SuperMix High Fidelity 

(Invitrogen), 0.3 μM of primers, and one μL of template. 

All nested PCR were followed by gel electrophoresis run 

on a 1.5% agarose gel at 150 volts for 30 minutes.

Purifying PCR products. Nested PCR products were 

purified using either QIAquick PCR Purification Kit or 

DNA Gel Extraction Kit (Qiagen) when multiproducts 

were produced, 20 μL of buffer was used to elute the 

final DNA product.

Multilocus sequence typing was performed as previously described.35 Briefly, purified PCR products were 

sequenced for both strands by using the Big-Dye terminator reagent (Applied Biosystems; Foster City, CA). 

Cycling temperatures were 25 cycles at 96°C for 10 

seconds, 50°C for 5 seconds, and 60°C for 4 minutes. 

Sequencing reactions were cleaned up by using gel cartridges and run on a 3130 automated sequencing analyzer (Applied Biosystems). To obtain the final sequence 

data, Chromas software (Technelysium; Queensland, 

Australia) and Vector NTI software (Invitrogen; Fredrick, MD) were used.

Results

Ticks collected. Eight hundred sixty-one ticks (0.4 per 

square meter) were collected by dragging a one meter 

square cloth for 100 meters at each of the sample sites 

on each date for a total of approximately 2,000 meters. 

Three hundred forty A americanum, 33 D variabilis, 

and 2 A maculatum were assessed for evidence of rickettsiae, B lonestari, E ewingii, and E chaffeensis. One 

I scapularis was assessed for Borrelia and Anaplasma

species. Four hundred eighty-two A americanum larvae 

and 3 nymphs collected from 3 sites were not included 

in this study. All 4 tick species collected are considered 

man-biting pests and vectors of disease.

Emerging Tick-borne Rickettsia and Ehrlichia

at Joint Base Langley-Eustis, Fort Eustis, Virginia
October – December 2016 25

The Army Medical Department Journal

Amblyomma americanum ticks assessed for Rickettsia, Borrelia and Ehrlichia: Purified nucleic acid preparations from the 340 (81 single adults, 34 single nymphs, 

and 15 pools of larvae) A americanum ticks selected for 

analysis were subject to qPCR testing for R amblyommii, B lonestari, E ewingii, and E chaffeensis (Table 1). 

Borrelia lonestari was detected in 2 male and 2 female 

A americanum adults for an infection rate of 5% of the 

adults tested. Ehrlichia chaffeensis was detected in one 

(1%) of the adult ticks tested, and E ewingii was detected 

in 2 (2%) adult and 2 (6%) of the nymph samples. Neither of these organisms were detected in the pools of 

larval ticks. Rickettsia amblyommii was detected in a 

minimum of 65 samples, and no further analysis was 

performed.

Dermacentor variabilis, A americanum and A maculatum ticks analyzed for Rickettsia species. Thirty three 

adult D variabilis, 2 female A maculatum and 340 adult 

and immature A americanum ticks were tested for rickettsiae (Tables 1, 2). All D variabilis ticks were negative, 

however, R amblyommii was detected in a minimum of 

63 A americanum ticks. Rickettsia species was detected 

in one of the 2 female A maculatum with the Rick17b 

and Rpark qPCR assays (Tables 1 and 2). Subsequently, 

the Rickettsia species positive DNA sample preparation 

from the R parkeri positive A maculatum adult tick was 

analyzed by multilocus sequence typing using ompA, 

ompB, and sca4 genes. Two fragments of ompA (648 

and 856 bp) and ompB (806 and 584 bp), and one fragment of sca4 (812bp) were 100% identical to R parkeri

Maculatum 20 (GenBank #AF 123717). The Candidatus

Rickettsia andeanae qPCR assay (Rande) was negative 

for the R parkeri positive sample.

The ubiquitous occurrence of A americanum collected at Fort 

Eustis along with the 

aggressive man-biting 

character of this tick 

species indicates that 

the potential risk of 

rickettsial and ehrlichial human infections 

could be high in the summer months in this area. Another possible public health threat is STARI, which 

has been documented following an A americanum tick 

bite.35 Even though R amblyommii and B lonestari have 

been suggested as possible agents of STARI, the true 

etiologic agent of this disease has yet to be identified.18,20

An additional potential health concern associated with 

A americanum is the recent discovery of R parkeri in 

Lone Star ticks collected in Tennessee and Georgia.37 In 

this study, we did not detect R parkeri in any of the A 

americanum ticks tested.

Dermacentor variabilis ticks are known to carry R 

rickettsii, the causative agent of RMSF, and R montanensis, a rickettsia of unknown human pathogenicity.38

No rickettsial agent was identified in the small number 

of D variabilis ticks assessed. This is not surprising 

since R rickettsii are rarely found in D variabilis, even 

in areas highly endemic for RMSF,39 and R montanensis is usually detected in only 5%-19% of D variabilis

evaluated.9,17,38

One of the 2 adult A maculatum ticks collected in this 

study was found to harbor R parkeri. A low number of 

Gulf Coast ticks identified in Fort Eustis or the Tidewater region is not surprising since its presence in this 

area and throughout Virginia has only been sporadically 

encountered.40,41 With that said, it is interesting that 2 of 

the first reported R parkeri rickettsiosis cases occurred 

in the Tidewater area of Virginia.10-11 R parkeri was initially isolated from A maculatum ticks in 193742 and has 

recently been found in multiple Amblyomma species 

such as Amblyomma triste,

12 A americanum,37,43 Amblyomma nodosum,

44 and experimentally in Amblyomma 

Table 1. Amblyomma americanum ticks collected by drag sampling at Joint Base Langley-Eustis, Fort Eustis, Virginia,

May-August 2009.

Life

Stage

Number

Collected

Number

Tested (N)

Borrelia lonestari

Number Positive (%N)

Ehrlichia chaffeensis

Number Positive (%N)

E ewingii

Number Positive (%N)

Rickettsia amblyommii

Number Positive (%N)

Adult 81 81 4 (5%) 1 (1%) 2 (2%) 34 (42%)

Nymph 37 34 0 (0) 0 (0) 2 (6%) 16 (47%)

Larva 707 225

(15 pools)

0 (0) 0 (0) 0 (0) 15 (7%) MIR*

*Minimum infection rate, larvae tested in pools of 15 individuals.

Table 2. Ticks collected by drag sampling at Joint Base Langley-Eustis, Fort Eustis, Virginia,

May-August 2009.

Tick Species Life

Stage

Number

Collected

Number

Tested 

(N)

Borrelia/Anaplasma

Number Positive 

(%N)

Rickettsia Species

Number Positive 

(%N)

Rickettsia parkeri

Number Positive 

(%N)

Amblyomma 

maculatum

Adult 2 2 Not tested 1 (50%) 1 (50%)

Dermacentor 

variabilis

Adult 33 33 Not tested 0 (0) 0 (0)

Ixodes 

scapularis

Adult 1 1 0 (0) Not tested Not tested
26 http://www.cs.amedd.army.mil/amedd_journal.aspx

cajennense.

45 The discovery of R parkeri infected ticks 

at Fort Eustis (in the Tidewater region of Virginia) combined with 2 Tidewater R parkeri human infections10,11

from the same region implies that residents of and visitors to the Tidewater area may be at risk of R parkeri

infections. In addition, A maculatum, endemic to the 

southern United States,40,41,46 may be widening its geographic range, implying that the geographic range of R 

parkeri is expanding as well. If the endemic region of A 

maculatum and R parkeri are growing, healthcare providers should be made aware of possible R parkeri rickettsiosis in their areas, and that Tidewater spotted fever 

has been confused for RMSF.4

 The results of this study 

reveal the need to learn more about the distribution of 

this vector in the Tidewater region, the prevalence of R 

parkeri infection of the Gulf Coast tick, and the incidence of Tidewater spotted fever in this area.

The inherent sampling bias of the cloth drag method 

is well explained by Schulze et al.47 However, in this 

instance it was employed as a surrogate to estimate 

rates at which a human may encounter ticks at Fort 

Eustis. Based on this assessment, the potential exists 

to encounter at least 4 ticks per 10 meters traveled on 

foot in natural, training, and recreational areas at Fort 

Eustis. Furthermore, pathogenic R parkeri, E ewingii 

and E chaffeensis which pose a risk to human health in 

the region were identified in 5% of the questing adult 

and nymph ticks collected from Fort Eustis. The predicted rate of encounter of an infected adult or nymph 

tick may be as high as 5 infected ticks per 100 meters 

traveled. Human rickettsial and ehrlichial diseases including RMSF and HME1

 are difficult to recognize and 

may be misdiagnosed due to their often cryptic symptoms. Since R parkeri has been recognized as a human 

pathogen only for the past few years, there is an even 

greater chance of misdiagnosis of R parkeri rickettsiosis. Indeed, one-third of supposed RMSF cases are believed to be misdiagnosed R parkeri cases.4

 Clinicians, 

therefore, should be aware of this condition. Moreover, 

studies are needed to determine the occurrence, distribution, and seasonality of A maculatum and R parkeri in 

the mid-Atlantic states of North Carolina, Virginia, and 

Maryland, which were previously not known to have 

long-established populations of A maculatum. Likewise, 

E chaffeensis and E ewingii, the discoveries of which 

occurred in 1986 and 1999, respectively, are also relatively unknown agents associated with the underreported disease HME and ewingii ehrlichiosis.24,25 Location 

of the diseases and their arthropod vectors are essential 

in informing medical health care providers, preventive 

medicine personnel, and the general population as to the 

risk of tick-borne diseases.48

Acknowledgement

This work was supported by the Department of Defense 

Global Emerging Infections System program work unit 

# 847705.82000.25GB.A0074.

The authors thank Ben Pagac for his review of this 

manuscript.

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15. Mixson TR, Campbell SR, Gill JS, Ginsberg HS, 

Reichard MV, Schulze TL, Dasch GA. Prevalence 

of Ehrlichia, Borrelia, and rickettsial agents in Amblyomma americanum (Acari: Ixodidae) collected 

from nine states. J Med Entomol. 2006;43:1261-1268.

16. Jiang J, Yarina T, Miller MK,Stromdahl EY, Richards AL. Molecular detection of Rickettsia amblyommii in Amblyomma americanum parasitizing humans. Vector Borne Zoonotic Dis. 2010;10:329-340.

17. Smith MP, Ponnusamy L, Jiang J, Ayyash LA, 

Richards AL, Apperson CS. Bacterial pathogens 

in ixodid ticks from a Piedmont County in North 

Carolina: prevalence of rickettsial organisms. Vector Borne Zoonotic Dis. 2010;10:939-952.

18. Masters EJ, Grigery CN, Masters RW. STARI, 

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19. James AM, Liveris D, Wormser GP, Schwartz I, 

Montecalvo MA, Johnson BJ. Borrelia lonestari

infection after a bite by an Amblyomma americanum tick. J Infect Dis. 2001;183:1810-1814.

20. Armstrong PM, Brunet LR, Spielman A, Telford 

SR III. Risk of Lyme disease: perceptions of residents of a Lone Star tick-infested community. Bull 

World Health Organ. 2001;79:916-925.

21. Childs JE, Paddock CD. The ascendancy of Amblyomma americanum as a vector of pathogens affecting humans in the United States. Annu Rev Entomol. 2003;48:307-337.

22. Merten HA, Durden LA. A state-by-state survey of 

ticks recorded from humans in the United States. J 

Vector Ecol. 2000;25:102-113.

23. Goddard J, Varela-Stokes AS. Role of the lone star 

tick, Amblyomma americanum (L.), in human and 

animal diseases. Vet Parasitol. 2009;160:1-12.

24. McQuiston JH, Paddock CD, Holman RC, Childs 

JE. The human ehrlichioses in the United States. 

Emerg Infect Dis. 1999;5:635-642.

25. Eng TR, Harkess JR, Fishbein DB, Dawson JE, 

Greene CN, Redus MA, Satalowich FT. Epidemiologic, clinical, and laboratory findings of human ehrlichiosis in the United States, 1988. JAMA. 

1990;264:2251-2258.

26. Buller RS, Arens M, Hmiel SP, et al. Ehrlichia ewingii, a newly recognized agent of human ehrlichiosis. N Engl J Med. 1999;341:148-155.

27. Davidson WR, Lockhart JM, Stallknecht DE, 

Howerth EW, Dawson JE, Rechav Y. Persistent Ehrlichia chaffeensis infection in white-tailed deer. J 

Wildl Dis. 2001;37:538-546.

28. Bell C, Patel R. A real-time combined polymerase 

chain reaction assay for the rapid detection and differentiation of Anaplasma phagocytophilum, Ehrlichia chaffeensis, and Ehrlichia ewingii. Diagn 

Microbiol Infect Dis. 2005;53:301-306.

29. Gusa AA, Buller RS, Storch GA, et al. Identification of a p8 gene in Ehrlichia ewingii: Evaluation of gene for use as a target for a speciesspecific PCR diagnostic assay. J Clin Microbiol. 

2001;39:3871-3876.

30. Loftis AD, Massung RF, Levin ML. Quantitative 

real-time PCR assay for detection of Ehrlichia 

chaffeensis. J Clin Microbiol. 2003;41:3870-3872.

31. Bacon RM, Pilgard MA, Johnson BJB, Piesman 

J, Biggerstaff BJ, Quintana M. Rapid detection 

methods and prevalence estimation for Borrelia 

lonestari glpQ in Amblyomma americanum (Acari: 

Ixodidae) pools of unequal size. Vector Borne Zoonotic Dis. 2005;5:146-156.

32. Barbour AG, Maupin GO, Teltow GJ, Carter CJ. 

Piesman J. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum: Possible agent of a Lyme disease-like illness. 

J Infect Dis. 1996;173:403-409.

33. Jiang J, Stromdahl EY, Richards AL. Detection 

of Rickettsia parkeri and Rickettsia andeanae in 

Amblyomma maculatum Gulf Coast ticks collected 

from humans, USA. Vector Borne Zoonotic Dis. 

2012;12:175-182.

34. Courtney JW, Kostelnik LM, Zeidner NS, Massung RF. Multiplex real-time PCR for detection of 

Anaplasma phagocytophilum and Borrelia burgdorferi. J Clin Microbiol. 2004;42:3164-3168.

35. Jiang J, Blair PJ, Felices V, et al. Phylogenetic 

analysis of a novel molecular isolate of spotted 

fever group rickettsiae from northern Peru: Candidatus Rickettsia andeanae. Ann NY Acad Sci.

2005;1063:337-342.
28 http://www.cs.amedd.army.mil/amedd_journal.aspx

36. Barbour AG, Maupin GO, Teltow GJ, Carter CJ. 

Piesman J. Identification of an uncultivable Borrelia species in the hard tick Amblyomma americanum: possible agent of a Lyme disease-like illness. 

J Infect Dis. 1996;173:403-409.

37. Cohen SB, Yabsley MJ, Garrison LE, et al. Rickettsia parkeri in Amblyomma americanum ticks, 

Tennessee and Georgia, USA. Emerg Infect Dis.

2009;15:1471-1473.

38. Bell EJ, Kohls GM, Stoenner HG, Lackman DB. 

Nonpathogenic rickettsias related to the spotted 

fever group isolated from ticks, Dermacentor variabilis and Dermacentor andersoni from eastern 

Montana. J Immunol. 1963;90:770-781.

39. Stromdahl EY, Vince M, Jiang J, Richards AL. Infrequency of Rickettsia rickettsii in Dermacentor 

variabilis removed from humans. Vector Borne 

Zoonotic Dis. 2011;11:969-977.

40. Sonenshine DE, Lamb JT Jr, Anastos G. The distribution, hosts and seasonal activity of Virginia ticks. 

Virginia J Sci. 1965;16:26-91.

41. Teel PD, Ketchum HR, Mock DE, Wright RE, 

Strey OF. The Gulf Coast tick: a review of the life 

history, ecology, distribution, and emergence as an 

arthropod of medical and veterinary importance. J 

Med Entomol. 2010;47:707-722.

42. Parker RR, Kohls GM, Cox GW, Davis GE. Observations on an infectious agent from Amblyomma 

maculatum. Public Health Rep. 1939;54:1482-1484.

43. Goddard J, Norment BR. Spotted fever group 

rickettsiae in the lone star tick, Amblyomma 

americanum (Acari: Ixodidae). J Med Entomol.

1986;23:465-472.

44. Ogrzewalska M, Pacheco RC, Uezu A, Richtzenhain LJ, Ferreira F, Labruna MB. Rickettsial 

infection in Amblyomma nodosum ticks (Acari: 

Ixodidae) from Brazil. Ann Trop Med Parasitol.

2009;103:413-425.

45. Sangioni LA, Horta MC, Vianna MCB, et al. Rickettsial infection in animals and Brazilian spotted fever endemicity. Emerg Infect Dis. 2005;11:265-270.

46. Estrada-Pena A, Venzal JM, Mangold AJ, Cafrune 

MM, Guglielmone AA. The Amblyomma maculatum Koch, 1844 (Acari: Ixodidae: Amblyomminae) 

tick group: diagnostic characters, description of the 

larva of A. parvitarsum Neumann, 1901, 16S rDNA 

sequences, distribution and hosts. Syst Parasitol.

2005;60:99-112.

47. Schulze TL, Jordan RA, Schulze CJ, Mixson T, Papero M. Relative encounter frequencies and prevalence of selected Borrelia, Ehrlichia, Anaplasma 

infections in Amblyomma americanum and Ixodes 

scapularis (Acari: Ixodidae) ticks from central New 

Jersey. J Med Entomol. 2005;42:450-456.

48. Feder HM Jr, Hoss DM, Zemel L, Telford SR III, 

Dias F, Wormser GP. Southern tick-associated rash 

illness (STARI) in the north: STARI following a 

tick bite in Long Island, New York. Clin Infect Dis. 

2011;53(10):e142-e146.

Authors

Ms Miller is an entomologist and Chief, Laboratory Sciences Division, Public Health Command Region-North, 

Fort Meade, Maryland.

Ms Jiang is a rickettsiologist in charge of laboratory detection, identification and characterization of rickettsial 

agents in the Rickettsial Diseases Research Program, Viral and Rickettsial Diseases Department, Naval Medical 

Research Center, Silver Spring, Maryland.

Ms Truong is an investment banking analyst at Stifel 

Nicolaus Weisel. She received a BS in Biology (Physiology and Neurobiology) and a BS in Finance from the 

University of Maryland, College Park, Maryland.

Ms Yarina is a microbiologist and currently a Masters 

of Public Health candidate focusing on epidemiology at 

George Washington University, Washington, DC.

Dr Evans is a postdoctoral fellow in the laboratory of 

Dr Edward Mitre, Department of Microbiology and Immunology, Uniformed Services University, Bethesda, 

Maryland.

Mr Christensen is a biological scientist overseeing the 

natural resources and entomology programs for Joint 

Base Langley-Eustis, Fort Eustis and assigned to the Environmental Element, Civil Engineer Division, 733 Mission Support Group, Fort Eustis, Virginia.

Dr Richards is a senior scientist and rickettsiologist, in 

charge of the Rickettsial Diseases Research Program, 

Viral and Rickettsial Diseases Department, Naval Medical Research Center, Silver Spring, MD. He is also an 

adjunct professor of the Emerging Infectious Diseases 

program and Preventive Medicine and Biometrics Department, Uniformed Services University of the Health 

Sciences, Bethesda, Maryland.

Emerging Tick-borne Rickettsia and Ehrlichia

at Joint Base Langley-Eustis, Fort Eustis, Virginia
October – December 2016 29

Hymenoptera envenomization poses an environmental 

threat during military contingency operations and venom hypersensitivity can pose a serious health hazard.1

Army Regulation 40-5012

 lists anaphylaxis to arthropod 

stings as a disqualifying medical condition. The US 

Army Medical Command issued a stinging insect policy providing additional assessment and management 

guidance of Soldiers with a possible allergy to stings.3

The Navy and Marine Corps follow guidelines in the 

Manual of the Medical Department 4

 which states that 

a current history of severe allergic reaction, anaphylaxis, or life threatening manifestations to environmental 

substances is a disqualifying condition for active duty 

service. Allergies that require allergy immunotherapy 

are also disqualifying unless a period of desensitization 

can be accomplished during a period of limited duty. 

However, there are medical or administrative waivers 

to gain entry into the US armed forces. In these cases, 

venom hypersensitivity must be clearly denoted on personnel medical documents, and medical/pharmacy departments are to ensure service members are equipped 

with epinephrine auto-injectors, especially during predeployment health screenings. Physicians can also issue 

service members with documented hypersensitivity to 

insect stings a medical warning tag per Bureau of Medicine and Surgery Instruction 6150.35.

5

In austere field settings where active duty personnel 

work, allergic reactions to Hymenoptera stings can be 

especially challenging, particularly since a history of 

allergic reactions to stings is many times not known previous to exposure. In the United States, half of all fatal 

reactions reportedly occur with no history of previous 

sting reactions.6

 Onboard ships and in field locations, a 

Navy corpsman or an Army medic with a small supply 

of medicines and equipment may be the only healthcare 

providers available. The standard medical bag carried 

by Marines in field settings or stocked on small Navy 

ships includes an epinephrine auto-injector (eg, EpiPen). 

For Navy Corpsman who work directly with operational 

units, including but not limited to Marines, Seabees, or 

other special operations, medical records are reviewed 

prior to any deployment or exercise. This is done to get a 

brief medical overview of the personnel they are responsible for, and ensure that proper medication is on hand 

in case of anaphylactic emergencies. Following instructions provided in the US Navy Manual of the Medical 

Department,

4

 specifically Article 21-3 12b, Navy corpsman will ensure that the service member who has an allergy to Hymenoptera stings has an epinephrine auto-injector issued to them and inspect to ensure the member 

possesses it before deployment. Individual commands 

may also write local instructions and policies specifying 

when it is mandatory for members to carry an EpiPen. 

This could also be a written directive from the member’s 

healthcare provider issuing the prescription (Manual of 

the Medical Department 4 Article 21-4). Directions accompanying an EpiPen also state that the device should 

be carried with the patient.

Honey Bee Swarms Aboard the

 USNS Comfort: Recommendations for

 Sting Prevention, Swarm Removal, and

 Medical Readiness on Military Ships

LCDR James C. Dunford, MSC, USN

CDR Karl C. Kronmann, MC, USN

HM1 Luke R. Peet, USN

CAPT (Sel) Jeffrey D. Stancil, MSC, USN

Abstract

The article provides observations of multiple honey bee (Apis mellifera) swarms aboard the USNS Comfort

(TAH-20) during the Continuing Promise 2015 mission. A brief overview of swarming biology is given along 

with control/removal recommendations to reduce sting exposures. The observations suggest that preventive medicine personnel should provide adequate risk communications about the potential occurrence of bee 

swarms aboard military ships, and medical department personnel should be prepared for the possibility of 

treating of multiple sting exposures, especially in the Southern Command Area of Operations where the Africanized genotype of A mellifera is common.
30 http://www.cs.amedd.army.mil/amedd_journal.aspx

Hymenoptera, the order of insects comprised of bees, 

hornets, wasps, and ants, tend to be more aggressive 

and apt to sting when there is greater sociality within a 

species.7

 Social or semisocial bees that live in colonies, 

especially near man-made structures, increase the risk 

of sting exposures for 2 primary reasons:

` Social bees are more sensitive to perceived threats 

in order to protect brood and food resources in the 

hive.

` Humans tend to prefer not to have them in close 

proximity and make efforts, often using counterproductive means, to rid the area of nesting or 

swarming bees.

During a 2010 deployment in support of Operation Enduring Freedom, a study was conducted to determine the 

prevalence of insect stings and venom hypersensitivity 

in military personnel operating in Afghanistan.1,8 Three 

species most commonly encountered by military personnel included social species in the superfamilies Apoidea 

(bees) and Vespodiea (wasps): Polistes wattii Cameron, 

Vespula germanica (Fabricius), and Vespa orientalis 

Linnaeus. These species were frequently observed near 

man-made structures located on military installations.

Highly social honey bee (Apis mellifera L.) colonies 

swarm for a variety of reasons. These swarms usually 

occur when bees move from one location to another to 

search for a site to construct a new hive, which is a natural means of honey bee reproduction. Swarming is initiated when the queen bee leaves the original hive with 

the rest of the colony following her movements. Because 

the queen is not a strong flyer, she will rest often, making the remainder of the colony stop along the way to 

new nesting sites. The swarming season is typically a 

4-6 week period and occurs in the late spring or early 

summer, but this may vary due to geographical location. 

Bees moving in the swarm tend to be less aggressive 

as there are no immatures (brood) to tend to or food to 

protect; however, because these bees are protecting the 

queen, any perceived threat may trigger an alarm pheromone resulting in bee stings to anything nearby. This 

may be especially important in the Southern Command 

Area of Operations (SOUTHCOM AOR) where the Africanized genotype of A mellifera is more prevalent. As 

of 2012, established populations of Africanized honey 

bees were found in every country in Central and South 

America except Chile.9

Africanized honey bees respond to food shortages by 

migrating and make small to large colonies that reproduce (swarm) often, ranging from 4-8 times a year.10 It 

is unclear if Africanized honey bees were encountered 

during the Continuing Promise 2015 mission discussed 

in this article because they are morphologically indistinguishable (without morphometric calculations) from 

the European honey bee. However, one key difference 

is that the Africanized genotype tends to swarm more 

commonly than the European genotype due to frequent 

hive overcrowding.9

 Africanized honey bees are also aggressively protective of their young and respond quickly 

by viciously stinging a suspected intruder and may attack more than 5 feet from the nest. It has also been 

noted that strong equipment vibration can activate Africanized honey bees from a distance of greater than 100 

feet.11 There is detailed biological and behavioral information on bee swarming in the literature and in various 

extension publications 12,13; thus, swarming behavior is 

not covered in great detail here.

The presence of bees or bee swarms may be an overlooked force health protection issue aboard ships while 

underway or in port. We report here the occurrence of 

at least 4 bee swarms and numerous honey bee reports 

aboard ship while deployed with the USNS Comfort

(TAH-20) in support of the humanitarian mission Continuing Promise 2015, which was conducted throughout 

much of the SOUTHCOM AOR. For this deployment, 

an entomologist was onboard to provide guidance on 

how best to manage the presence of bees to prevent sting 

exposures; however, supplies were not available to remove bees if required. Personnel on less well-informed 

ships may sustain unnecessary stings due to inappropriate removal tactics and lack of knowledge about bee 

behaviors. This may be especially important on ships 

without adequate medical services to respond to severe 

sting reactions.

Upon conducting a literature search using Google online search terms “honey bee,” “swarms,” “Navy,” “military,” “ships,” we could not find any previous reports of 

bee swarming aboard military ships. While bee swarming has apparently not been previously documented, it 

is not a new phenomenon. Along with our observations 

aboard USNS Comfort, we have received other anecdotal reports of bee swarms aboard various seafaring 

vessels including previous missions aboard the Comfort. 

Bee swarms were observed on USS Iwo Jima (LHD-7) 

on a forklift as shown in Figure 1 during Continuing 

Promise 2010 (R. Flores, written communication), and 

on USNS Comfort during Continuing Promise 2011 as 

observed by author J. D. Stancil. In 2014, a large bee 

swarm was observed on a crash and salvage crane 

aboard the USS Peleliu (LHA-5) while pierside in the 

Republic of Philippines (C. Guckeyson, written communication) (Figure 2). Navy Environmental and Preventive Medicine Unit-6 (NEPMU-6) preventive medicine personnel responded to swarms aboard USS Preble

Honey Bee Swarms Aboard the USNS Comfort: Recommendations for Sting

Prevention, Swarm Removal, and Medical Readiness on Military Ships
October – December 2016 31

The Army Medical Department Journal

(DDG-88) and USS Port Royal (CG-73) while the ships 

were in port in Pearl Harbor, Hawaii, in 2014 (E. Gerardo, written communication). To the best of our knowledge, however, this article is the first effort to formally 

document this phenomenon and develop hypotheses as 

to why it occurs aboard ships. In this note, we document 

our observations, provide recommendations to prevent 

sting exposures, and offer solutions to the safe removal 

of bees during shipboard operations. We hope this leads 

to a better understanding of bee swarming behavior and 

the ability of shipboard personnel to prepare for this potential health risk.

Honey Bee Observations

During the Continuing Promise 2015 mission, bee 

swarms on the USNS Comfort were first noted while at 

anchor near the coast of Guatemala on April 23, 2015. 

Within 2 days after dropping anchor approximately 8 

miles off the coast of the port city Puerto Barrios, a bee 

swarm was reported near the ship’s bridge. The swarm 

was encompassing a utility box covering a thermometer 

located on the bridge (Figure 3). The bees were not aggressive, although at least one sting was reported. Many 

of the bees were vibrating their wings, likely in an attempt to regulate the ambient temperature for the queen 

and maneuvered around the box to avoid being in direct 

sunlight. Rapid wing vibrations may also have been a 

result of worker bees releasing pheromones using their 

wings to disseminate chemicals to orient forager bees 

back to the colony. The total number of bees slowly declined until all bees had left the area within 48 hours 

of initial reports. There were also numerous individual 

bees reported in many areas of the ship throughout the 

time it was anchored at this location. These may have 

been scout bees from the swarm looking for a suitable 

place to nest.

At least 3 bee swarms were again noted while pierside in 

Acajutla, El Salvador, starting on June 17. Swarms were 

reported within the first day of arrival. Swarms were located on an antenna located towards the bow (forward) 

(Figure 4) on June 17, an air conditioning unit towards 

the stern of the ship (aft) (Figure 5) on June 18, and the 

base of an aft antenna (Figure 6) on June 19. The bee 

swarm located on the forward antennae departed within 

24 hours of first being observed, and it is not clear if this 

group moved to different locations noted for the other 2 

sightings. The bee swarm located on the aft air conditioning unit remained until June 21, but the number of 

bees appeared to decline daily from initial reports. In 

Figure 1. Bee swarm (red arrow) on a forklift aboard the USS 

Iwo Jima (LHD-7). Image courtesy of HM1 Robert Flores.

Figure 2. Bee swarm (red box) on crash and salvage crane 

aboard the USS Peleliu (LHA-5). Photo courtesy of HMC Chris 

Guckeyson.
32 http://www.cs.amedd.army.mil/amedd_journal.aspx

addition, this location on the upper portion of the ship 

had numerous dead bees located near the air conditioning units. The bee swarm located on the aft antenna on 

June 18 had departed by June 21. Although no swarms 

were observed, numerous individual bee sightings and 

complaints were also made aboard ship at a port stop in 

Colón, Panama, between June 30 and July 5.

Medical Reporting of Hymenoptera Stings

We mined medical records in the ship’s log for any reported Hymenoptera stings or suspected allergic reactions to bee stings. During the mission, 7 patients reported to sick bay for arthropod-related stings or bites. 

Three were classified as general bug bites, two were 

spider bites, and two were attributed to bee stings. One 

of the bee stings was reported on April 28 by a civil 

mariner, and an active duty service member reported 

Honey Bee Swarms Aboard the USNS Comfort: Recommendations for Sting

Prevention, Swarm Removal, and Medical Readiness on Military Ships

Figure 3. Bee swarm on thermometer box aboard USNS Comfort (TAH-20) off the coast of Guatemala. Photo provided by 

LCDR J. Dunford.

Figure 5. Bee swarm on air conditioning unit aboard USNS 

Comfort (TAH-20) in port in Acajutla, El Salvador. Photo courtesy of LCDR J. Dunford.

Figure 6. Bee swarm on base of aft antenna aboard USNS 

Comfort (TAH-20) in port in Acajutla, El Salvador. Photo courtesy of HM1 L. Peet.

Figure 4. Bee swarm (red box) on antenna aboard USNS Comfort (TAH-20) in port in Acajutla, El Salvador. Photo courtesy of 

LCDR J. Dunford.
October – December 2016 33

The Army Medical Department Journal

the other bee sting June 18. The bee stings were reported during mission stops (Guatemala and El Salvador) in 

which bee swarms were observed aboard ship. No serious reactions were reported for any of the arthropodrelated stings or bites.

Recommendations

Most bee swarms, especially aboard a ship where no 

food sources (eg, flowers) are readily available in close 

proximity, will leave on their own in a few hours or days. 

Accordingly, a simple rule of thumb is to not panic, and 

maintain a safe distance from the swarm. Many sting 

exposures are due to unnecessary aggravation of the 

swarm, such as throwing objects or spraying various 

substances in an attempt to get them to move on. Bees 

are typically docile during swarming unless provoked 

by an inappropriate attempt to rid the area of the swarm. 

A first reaction might be to use insecticide applications, 

but this is not recommended. Insecticide applications 

may provoke the bees, and is completely unnecessary 

unless the bee swarm appears to be building cells for 

nesting or where operational commitments dictate immediate bee removal. If a swarm cannot be allowed to 

leave naturally, the first option is to consider hiring a 

professional bee removal service to remove and safely 

relocate the swarm. However, this option is typically 

not possible during shipboard contingency missions 

unless a local vendor is available for hire while in port. 

We recommend contacting the US Embassy in the port 

country to determine if a suitable vendor is available 

and has been vetted for pest control services. Because of 

the value of honey bees in crop production, bee removal 

is often done for free or for a minimal charge. This may 

be a viable option while in port, especially in the United 

States, for long periods of time. Local farmers and national beekeepers associations may also be contacted for 

bee removal services.

During contingency missions or in foreign ports, especially those in the SOUTHCOM AOR where the Africanized honey bee genotype is more prevalent, we recommend reporting bee swarms immediately to preventive medicine personnel. They should then work with 

the appropriate shipboard personnel to set up a safe 

perimeter around the bee swarm until it departs. Based 

on author J. C. Dunford’s observations of bee swarm behavior aboard the USNS Comfort, a safe perimeter is 

at least 25 feet from the swarm as illustrated in Figure 

7. It should be noted that Africanized honey bees can 

perceive threats 50 feet or more away from their nest; 

however, swarms tend to be more docile. The perimeter should be clearly marked with ‘Do Not Enter’ signs 

along with information about the presence of a bee 

swarm. This area should then be checked periodically 

by preventive medicine or other informed personnel until the swarm has moved on. During Continuing Promise 2015, the ship’s Master at Arms played an important 

role in locating bee swarms, reporting, and directing his 

personnel to follow the recommendations of the Directorate for Public Health. Keeping personnel a safe distance away from swarms not only prevents intentional 

exposure (eg, during inadequate attempts to remove the 

bees), but also accidental exposure, as we found that in 

many cases individuals transiting the decks were not 

aware of the presence of the bees. Operating equipment 

that creates strong vibrations near a bee swarm is also 

not advisable as this may trigger the bees to react to 

perceived danger.

Although the swarm is likely to depart its temporary 

resting site within a few hours or days, the swarm’s location may hinder operational duties or may be located in 

a space frequented by personnel that require access to it. 

In addition, if scout bees leaving the swarm are unable 

Figure 7. Civil mariner blocking area with bee swarm (red box) 

on base of antenna (also shown in Figure 4) aboard USNS 

Comfort (TAH-20) in port in Acajutla, El Salvador. Photo courtesy of LCDR J. Dunford.
34 http://www.cs.amedd.army.mil/amedd_journal.aspx

to find a suitable nesting site, the swarm may start construction of their combs on a structure on which they 

have clustered, even though this would not be optimal 

for the colony on a ship. For the bees, a suitable nesting 

location may be an area well protected from the elements, 

receive a certain amount of warmth from the sun, and 

be 15 liters in volume. When these circumstances exist, 

there may be no other option but to destroy the swarm 

to prevent sting exposures. We recommend that preventive medicine units consider procuring a beekeeping suit 

for shipboard missions, especially in the SOUTHCOM 

AOR, as part of their entomological equipment build, as 

it is the only effective means to protect personnel applying insecticides or attempting to relocate a swarm, 

especially Africanized honey bee swarms. If feasible, 

relocation of the colony is possible by following techniques often used by beekeepers but should be done so 

only with proper personal protective equipment (ie, full 

beekeeping suit; or fire suit, keeping in mind potential 

heat stress issues) ensuring all exposed skin is covered 

and gaps between the head gear, suit, gloves, and boots 

are sealed (or tucked in) using rubber bands, Velcro, or 

duct tape.

Beekeepers may use traps baited with Nasonov pheromone to attract swarming bees. This naturally occurring pheromone consists of several terpenoids and is 

used to orient foraging bees back to the colony. Other 

capture methods include using a bee vacuum or equivalent with enough suction to collect all of the bees in a 

container to keep them from escaping after being captured. A suitable box with a small opening called a nuc 

(similar to empty beehive) can also be used. If a bee 

swarm is encountered, a white sheet can be placed under 

the swarm location with a nuc box placed on the middle 

of the sheet. The swarm can be sprayed with a sugar 

solution and then shaken or scrapped off the resting surface into the nuc. If the queen does enter the nuc, most of 

the remaining colony will follow soon thereafter. This 

capture method can only be performed during the day 

and should be done wearing personal protective equipment described earlier.

As a last option, insecticides approved for bee control 

can be used to destroy the swarming colony. Given the 

recent decline in bee populations in many parts of the 

world, we do not recommend destroying honey bee colonies; however, mission objectives may require this action. Department of Defense approved pesticides should 

be used strictly following label instructions and used 

only by pesticide applicator certified personnel (if required following insecticide label). A current list of approved pesticides can be found at the Armed Forces Pest 

Management Board web site (http://www.acq.osd.mil/

eie/afpmb/). All personnel, including onlookers, should 

be adequately protected or clear of the area to prevent 

bee sting exposures during insecticide applications. Insecticides should be applied directly to the swarm and 

dead bees should be removed from the area and discarded. As an alternative, spraying soapy water (one cup of 

liquid dishwashing detergent per gallon of water) in a 

high volume spray may also be used and applied using 

maximum personnel protective gear such as a beekeeping suit. Preventive medicine personnel from NEPMU-6 

responding to a bee swarm aboard the USS Port Royal

used this technique to successfully neutralize over 1,000 

bees (E. Gerardo, written communication). Other surfactants, such as aqueous film firefighting foams will 

also work. Specific surfactant examples include Palmolive dishwashing liquid, 9-55 fire control chemical, Sivex Rfoam concentrate, and FC-600 aqueous film-foam.14

In the unfortunate case that bees are attacking, personnel must exit the area as quickly as possible. Africanized 

honey bees will continue to defend their nest for a distance of a 1⁄4 mile or more; thus, it is important to protect 

the head, eyes, nose, and mouth with hands, arms, or 

clothing. Enter a sheltered area to get away from the majority of the swarm and seek medical attention if stung. 

The lethal dose of bee venom for a human is approximately 10 stings per pound of body weight.10 If one or 

a few stings are noted, practical first aid measures such 

as stinger removal by scraping using a fingernail, dull 

knife, or credit card are warranted. The patient should 

then be monitored for any signs of anaphylaxis. Betten et al 15 consider a massive attack to be 50 stings or 

more. When the number of stings is less than 50, and the 

victim is not hypersensitive to the venom and properly 

treated, conservative, supportive care is appropriate.9

 It 

should be noted that about half of the people who have 

anaphylactic reactions to bees stings do not have a history of bee allergies, and victims should be specifically 

questioned about warning symptoms such as development of hives, breathing difficulties, or dizziness which 

are not always recognized immediately due to the distraction of the painful stings.

Although the toxicity of Africanized honey bees is similar to the European honey bee, multiple stings in a short 

period of time can cause severe allergic reactions. Massive envenomization is rare, and treatment of severe allergic reactions includes management of shock, hypoxia, and other effects on the organs. Personnel with no 

known bee allergies are still at risk for systemic anaphylaxis as discussed above, which may be exacerbated by 

multiple bee stings 16 which is often seen when attacked 

by Africanized honey bees. Although rare, strokes have 

also been reported following multiple bee stings.17 The 

Honey Bee Swarms Aboard the USNS Comfort: Recommendations for Sting

Prevention, Swarm Removal, and Medical Readiness on Military Ships
October – December 2016 35

The Army Medical Department Journal

cosmopolitan distribution and prevalence of A mellifera

(and Hymenoptera in general) increases the likelihood 

that adults have had previous sting exposures to various 

genotypes of this species. Based on studies evaluating 

the cross-reactivity of insect venoms, it can be assumed 

that closely related species would likely pose a greater 

threat to an individual with previous sting exposures 

during one’s lifetime 18,19; thus, insect venom hypersensitivity in service members should be closely and continuously monitored. Predeployment questionnaires during 

overseas health screenings should clearly denote known 

history of Hymenoptera venom sensitivity and treatment should be available. Medical departments should 

also ensure readiness for bee stings including protocols 

to treat massive envenomization or patients with hypersensitivity to Hymenoptera venom. Upon embarkation, 

the USNS Comfort had 8 EpiPen injectors available for 

use, in addition to aqueous epinephrine stocked in the 

ship’s pharmacy. While the Comfort has a well-supplied 

pharmacy, there are no formal instructions on how other 

vessels should be stocked. Predeployment force health 

protection briefs should include awareness of stinging 

insects and emphasize avoidance measures to limit contact with potentially aggressive Africanized honey bee 

colonies.

Comment

During Continuing Promise 2015, bee encounters were 

the most numerous arthropod-related complaints from 

crew aboard ship. Bees apparently use ships as an intermediate stop before finding a suitable location to 

build a new hive, and we speculate that bee swarms may 

be attracted to artificial cues emitted by antennas and 

other mechanical equipment aboard ship. There were 

several areas on the ship where vibrations, heat, visual, 

or olfactory emissions may have attracted swarming 

colonies. Air conditioning units on the ship vibrate and 

radio antennas may also transmit vibrations via subtle 

wavelengths; bee swarms were noted at both such locations during Continuing Promise 2015. Gilbert et al 20

noted that vibration signals may influence nest-site 

selection in honey bees by enhancing scouting and recruitment. Vibration signal activity and recruitment or 

waggle dances are known to play a role in colony liftoff 

preparations and swarm movement within colonies.21 A 

primary function of these signals during house-hunting 

may be to generate a level of activity in workers that coordinates responses that stimulate departure and movement to new nesting locations. It is unclear if subtle vibrations transmitted by equipment on the ship played a 

role in attracting or interfering with the colony’s ability 

to find suitable nesting locations; thus, further investigation into bee swarming on ships and where colonies 

are observed resting is needed. Alternatively, a ship may 

simply be a large object on which to to rest along the 

way to finding suitable nesting sites.

Adequate risk communication on bee swarming is important to reduce fear of bee sting exposures and prevent unnecessary attempts to remove bees. Honey bee 

(or Hymenoptera in general) biology and avoidance 

countermeasures should be passed to ship’s crew before 

and periodically during contingency missions. Previous 

to disseminating this information during Continuing 

Promise 2015, the presence of the bees caused undue 

alarm as well as failed attempts to rid the area of bees, 

resulting in some reported bee stings where treatment 

was not sought. In some cases, the bee swarms went unnoticed (increasing the risk for accidental exposure) by 

personnel transiting the affected areas. Using the name 

Africanized honey bee and not “killer bee” is preferable 

during force health protection briefings to reduce the 

normal fear associated with the latter, often misleading 

description of honey bees in the SOUTHCOM AOR.

Based on what is known about bee swarming biology, 

we do not recommend attempting to kill bees using insecticides for a variety of reasons, including safety of 

ship’s personnel as well as recent decline in bee populations worldwide. In most instances, bee swarms will 

move on within hours or a couple of days after arriving 

aboard a ship. It should be noted that honey bees, including Africanized varieties, are beneficial insects for their 

pollination services. Honey bees have also been trained 

to detect explosives and diseases such as cancer.22,23 The 

frequency and temporal trends of encountering large 

bee swarms during shipboard operations is not well 

documented, and lack of preventive countermeasures 

in advance may leave few options for bee removal and 

adequate risk communications to prevent sting exposures. We hope that this information provides preventive medicine/medical departments several options to 

prepare for such phenomenon during predeployment 

supply acquisitions, and provides a template to issue risk 

communications in the plan of the day or during other 

force health protection briefs for widest dissemination. 

Although swarming bees can be alarming to ship’s crew, 

sting exposures can be minimized with proper preparation and adequate avoidance measures. Our overarching 

goal is to improve risk communication on bee swarms 

and bee stings, and we encourage additional reporting 

of bee swarms aboard ships during future missions.

Acknowledgements

We thank LTJG Elizabeth Gerardo for providing information regarding recent technical assist visits conducted 

by Navy Environmental and Preventive Medicine Unit6 to control bee swarms, HMC Chris Guckeyson for 
36 http://www.cs.amedd.army.mil/amedd_journal.aspx

providing information and corresponding image on bee 

swarm observations aboard USS Peleliu, HM1 Robert 

Flores for information and corresponding image aboard 

USS Iwo Jima, HM3 Jonathan Torres for assistance in 

gathering medical data, and Military Sealift Command 

civil mariners aboard USNS Comfort for reporting bee 

sightings. We also thank USNS Comfort Medical Treatment Facility Commanding Officer CAPT Christine 

Sears for supporting this work during Continuing Promise 2015, and LT Paula Volk and LTJG Christian Johnroe 

for reviewing and greatly improving earlier drafts of this 

manuscript.

References

1. Turbyville JC, Dunford JC, Nelson MR. Hymenoptera of Afghanistan and the central command area 

of operations: assessing the threat to deployed US 

service members with insect venom hypersensitivity. Allergy Asthma Proc. 2013;34:179-184.

2. Army Regulation 40-501: Standards of Medical 

Fitness. Washington, DC: US Department of the 

Army; 2007 (revised 2011):17. Available at: http://

www.apd.army.mil/pdffiles/r40_501.pdf.

Accessed November 21, 2015.

3. US Army Office of the Surgeon General/Medical 

Command Policy Memo 07-307: Stinging Insect 

Policy. Fort Sam Houston, TX: US Army Medical 

Command; 2007. Available at: http://www.afpmb.

org/sites/default/files/contingency/Stinging_Insects_Policy.pdf. Accessed November 21, 2015.

4. Manual of the Medical Department: NAVMED 

P-117. Washington, DC: US Department of the 

Navy; 2005 (update 2016). Available at: http://

www.med.navy.mil/directives/Pages/NAVMEDPMANMED.aspx. Accessed May 26, 2016.

5. Bureau of Medicine and Surgery Instruction 

6150.35: Medical Warning Tag. Washington, DC: 

US Department of the Navy; July 1991. Available 

at: http://www.med.navy.mil/directives/External

Directives/6150.35.pdf. Accessed May 26, 2016.

6. Golden DBK. Insect sting anaphylaxis. Immunol 

and Allergy Clin North Am. 2007;27:1-11.

7. Pankiw T. Reducing honey bee defensive responses 

and social wasp colonization with methyl anthranilate. J Med Entomol. 2009;46:782-788.

8. Dunford JC, Turbyville JC, Leavengood JM Jr. 

Checklist of medically important Hymenoptera 

of Afghanistan. Insecta Mundi. 2014;0339. Available at: http://digitalcommons.unl.edu/cgi/viewcon

tent.cgi?article=1843&context=insectamundi. Accessed May 26, 2016.

9. Ferreira RS Jr, Almeida RA, Barraviera SR, Barraviera B. Historical perspective and human 

consequences of Africanized bee stings in the 

Americas. J Toxicol Environ Health B Crit Rev. 

2012;15(2):97-108.

10. Armed Forces Pest Management Board. Technical Guide 34: Bee Resource Manual with emphasis on the Africanized Honey Bee. Silver Spring, 

MD: Armed Forces Pest Management Board; 2013. 

Available at: http://www.acq.osd.mil/eie/afpmb/

docs/techguides/tg34.pdf. Accessed May 26, 2016.

11. Occupational Safety and Health Administration. 

Africanized Honey Bee [internet]. 2014. Available 

at: http://www.oshasafetymanuals.com/african

ized-honey-bee/. Accessed November 21, 2015.

12. Seeley TD, Visscher K, Passino KM. Group decision making in honey bee swarms. Am Sci. 

2006;94:220-229.

13. DeBerry S, Crowley J, Ellis JD. Swarm control for 

managed bee hives [internet]. Gainesville, FL: University of Florida Institute of Food and Agricultural 

Sciences; 2012;ENY-160. Available at: http://www.

edis.ifas.ufl.edu/in970. Accessed May 26, 2016.

14. US Department of Agriculture. Africanized Honey 

Bees [internet]. 2011. Available at: http://www.ars.

usda.gov/Research/docs.htm?docid=11059&pf=1. 

Accessed November 21, 2015.

15. Betten DP, Richardson WH, Tong TC, Clark 

RF. Massive honey bee envenomation-induced 

rhabdomyolysis in an adolescent. Pediatrics. 

2006;117(1):231-235.

16. Sherman RA. What physicians should know 

about Africanized honey bees. West J Med. 

1995;163:541-546.

17. Rajendiran C, Puvanalingam A, Thangam D, Ragunanthanan S, Ramesh D, Venkatesan S, Sundar 

C. Stroke after multiple bee sting. J Assoc of Physicians India. 2012;60:122-124.

18. Reisman RE, Müller UR, Wypych JI, Lazell 

MI. Studies of coexisting honeybee and vespid-venom sensitivity. J Allergy Clin Immunol. 

1984;73(2):246-252.

19. Goldberg A, Confino-Cohen R, Mekori YA. Deliberate Hymenoptera sting challenge as a diagnostic tool in highly selected venom-allergic patients. 

Ann Allergy Asthma Immunol. 1995;75:30-32.

20. Gilbert S, Lewis LA, Schneider SS. The role of vibration signal during nest-site selection by honey 

bee swarms. Ethology. 2011;117(3):254-264.

21. Donahoe K, Lewis LA, Schneider SS. The role of 

vibration signal in the house-hunting process of 

honey bee (Apis mellifera) swarms. Behav Ecol Sociobiol. 2003;54:593-600.

22. Los Alamos National Laboratory. Detecting explosives with honeybees: experts develop method 

to train air force of bomb-sniffing bees. Science 

Daily [internet] 2006. Available at: http://www.

sciencedaily.com/releases/2006/11/061128140820.

htm. Accessed November 21, 2015.

Honey Bee Swarms Aboard the USNS Comfort: Recommendations for Sting

Prevention, Swarm Removal, and Medical Readiness on Military Ships
October – December 2016 37

The Army Medical Department Journal

23. Halter R. Bees: man’s best friend, provider and protector [internet]. The Telegraph. November 2, 2010. Available at: 

http://www.telegraph.co.uk/news/science/8104213/Bees-mans-best-friend-provider-and-protector.html. Accessed 

November 21, 2015.

Authors

LCDR Dunford is a USN medical entomologist who was deployed with the Directorate for Public Health, USNS Comfort

during Continuing Promise 2015. He is currently assigned to the Navy and Marine Corps Public Health Center, Portsmouth, Virginia. 

CDR Kronmann is a USN infectious disease and internal medicine physician who was Director, Directorate for Public 

Health, USNS Comfort during Continuing Promise 2015. He is currently Associate Director for Public Health Services, 

Naval Medical Center, Portsmouth, Virginia.

HM1 Peet is a USN preventive medicine technician who was deployed with the Directorate for Public Health, USNS 

Comfort during Continuing Promise 2015. He is currently assigned to Boone Clinic, Joint Expeditionary Base-Little 

Creek, Virginia.

CAPT (Sel) Stancil, a USN medical entomologist, is Officer-in-Charge, Navy Entomology Center of Excellence, Naval 

Air Station-Jacksonville, Florida.
38 http://www.cs.amedd.army.mil/amedd_journal.aspx

Fungal diseases rarely cause death in healthy young 

people. Both obligate parasitic fungi and opportunistic 

pathogens cause these diseases. Some military personnel are infected in their work environment with fungal 

pathogens such as the agents of histoplasmosis and 

coccidioidomycosis. Certain fungal diseases pose an 

increased threat to military personnel and retirees because of the frequency of serious wounds, amputations, 

and organ transplants compared to the overall civilian 

population. The Department of Veterans Affairs treats 

veterans and retirees for wounds and diseases acquired 

while in service.

There are ample reviews of historic disease trends in the 

US military; however, little comprehensive work has focused on all fungal deaths in the US Air Force (USAF).1

Previous reviews of zoonotic disease morbidity in the 

USAF did not consider fungal disease zoonotic,2

 even if 

some derive from animal exposure. The US Air Force 

School of Aerospace Medicine maintains the Air Force 

Mortality Registry (AFMR). The AFMR is a unique 

resource that creates a database of all mortality data 

from death certificates, autopsy reports, etc, for active, 

reserve, and retired USAF service members to track 

trends and patterns that are more precise than Department of Defense casualty data. The AFMR tracks all 

causes of death including those from occupational and 

fungal diseases. We review those deaths in the context 

of historical disease significance and modern trends.

Materials and Methods

We queried 442,856 AFMR death records for all deaths 

after December 31, 1969, to December 31, 2012. The 

AFMR uses the International Classification of Diseases-10th Revision (ICD-10) codes to track causes of 

death. Death records were accessed when the ICD-10 

code matched any of the following (or their subsections): 

aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, histoplasmosis, mucormycosis, pneumocystosis, sporotrichosis, zygomycosis, and 

unspecified mycosis. We analyzed each record. We further examined the death certificates which cite unspecified mycosis in an attempt to verify the fungal cause of 

death. We also examined death certificates in detail to 

verify place of death and other causes of death, if any. 

The death records included in this study were those of 

all individuals reported to have had a fungal disease as 

underlying cause of death. We used SAS 9.3 (SAS Institute Inc, Cary, NC) software for our analysis.

Results and Comment

Overall, there were 216 deaths from fungal diseases 

from 1970-2012, summarized in the Table. There are 

limits to the data in the AFMR. Death records prior 

to the mid-1980s are sparsely represented and not all 

recent deaths have been documented, so records after 

2010 could be underrepresented.

Pathogenic and parasitic fungi are ubiquitous but rarely 

cause death in the developed world. They are often associated with travel, the elderly, or a compromised immune system. Fatalities from fungal diseases are most 

often seen in the elderly as secondary infections, following organ transplants or chronic disease. Some fungi 

are legitimate parasites while others are only opportunistic environmental pathogens. We address each fungal pathogen alphabetically instead of following phylogenetic order.

Aspergillosis: Aspergillus spp are truly ubiquitous 

fungi with airborne conidia throughout the world.3

They produce aflatoxins, but we did not consider any 

deaths related to these toxins. Aspergillus spp are saprophytic fungi, but aspergillosis threatens patients who 

Mortality From Fungal Diseases in the

 US Air Force From 1970 to 2013

Richard K. Kugblenu, MPH

Will K. Reeves, PhD, MS

Abstract

We review a unique set of documents, death certificates, catalogued in the US Air Force Mortality Registry, 

which tracks deaths for current and retired Air Force service members. We screened the records for all deaths 

caused by fungal diseases between 1970 and 2013. There were 216 deaths caused by a variety of diseases such 

as aspergillosis, blastomycosis, candidiasis, coccidioidomycosis, cryptococcosis, histoplasmosis, mucormycosis, pneumocystosis, sporotrichosis, and zygomycosis. The single most common identified cause of death was 

opportunistic candidiasis. Of the total 216 deaths, only 7 were active duty or active reserve personnel.
October – December 2016 39

The Army Medical Department Journal

are immunocompromised, and fatal 

cases of aspergillosis increased after 

the introduction of corticosteroids 

and immunosuppressant drugs.4

 Aspergillosis is currently the leading 

cause of fungal deaths in the United 

States.3

 It was the second most common cause of death in the study, with 

36 deaths. The first death recorded 

in the AFMR was in 1989. Sixtyone percent (n=22) of aspergillosis 

deaths were recorded from 2000 to 

2012, with 1 and 13 deaths recorded 

for the 1980s and 1990s, respectively. 

We have not found a record of a female death thus far. The deceased 

were retirees, 55 years and older, the 

majority of whom died of pulmonary 

infections.

Blastomycosis: Blastomyces dermatitidis causes this relatively rare fungal disease. Most cases in the United 

States were acquired in the eastern 

half of the country, with a rate of approximately 2 per 100,000 people.5

This disease is relatively rare, with 

a low overall rate of mortality, but 

in some studies the death rate can 

exceed 12% in individuals over 65 

years of age.5 In the USAF, there were 

4 deaths, all of which were retired 

males with either disseminated or unspecified infection 

sites. Four deaths were recorded from 1999 to 2003, with 

one death per year, 2001 being an exception. There were 

no records of death from blastomycosis after 2003.

Candidiasis: Numerous Candida spp cause candidiasis, 

with Candida albicans being the most frequently reported.6 Disseminated or invasive candidiasis is one of the 

most prominent fungal causes of mortality in the United 

States. While invasive candidiasis is rare in people without risk factors, it is the fourth most common cause of 

hospital-acquired bloodstream infections in the United 

States.6

 Patients often acquire candidiasis following a 

traumatic injury or organ transplantation, or after suppression of the immune system due to age and/or other 

illness. Almost all of the 43 deaths (91%) recorded in 

the AFMR were men over the age of 60. While we are 

unable to know if they were suffering from underlying 

conditions, that is probable. A majority of cases (n=20 

(46%)) were recorded from 2000-2012, preceded by 16 

(37%) in the 1990s.

Coccidioidomycosis: This disease is 

generally restricted to the western 

United States, where the causative 

agent Coccidiodes immitis is endemic. It is an occupational hazard for 

military personnel training where 

soil is disrupted, such as on bombing ranges.7

 Coccidioidomycosis 

contributed the third highest number 

of fungal deaths during our study 

period. Coccidioidomycosis was one 

of the most significant fungal causes 

of death for USAF retirees, with 32 

deaths. There is no way of knowing if they acquired the infections 

while on active duty. It also caused 

3 deaths of active duty airmen, with 

a death in 1970, 1972, and 1992. Of 

these, approximately 75% died in 

western states, and the other cases 

could have been acquired there and 

reported at the site of death. Almost 

half of the deaths (n=15 (46%)), were 

recorded in the 1990s.

Cryptococcosis: Several Cryptococcus spp cause cryptococcosis. Cryptococcus gattii causes disease and is 

most common in immunocompetent 

people.8 Cryptococcus neoformans 

is associated with animals and Cryptococcus gattii is more associated 

with certain trees and contaminated 

habitats.8

 Both pathogens cause cryptococcosis and are 

reported identically in death records. The pathogens are 

regionally focal. Fatal cases of cryptococcosis often involve fungal meningitis.9

 Cryptococcosis is one of the 

most significant opportunistic infections for human immunodeficiency virus (HIV) patients, with an incidence 

rate of 0.04% to 12% worldwide, and up to 70% mortality.9

 The death of a 42-year-old male on active duty was 

recorded in 1985. All other cryptococcosis deaths were 

retirees. Ninety-one percent of the deceased were male, 

with one recorded as “null.” Most cases were reported 

in the 1990s (41.67%), which might be related to the acquired immunodeficiency syndrome (AIDS) epidemic.

Histoplasmosis: Histoplasmosis is a disease caused by 

Histoplasma capsulatum. It is a dimorphic soil fungus 

(Emmonsiella capsulatum) often associated with animal 

feces.10 The parasitic form of histoplasmosis usually 

invades the lungs. Histoplasmosis is known to be one 

of the more common, yet very serious, fungal diseases 

in older Americans.11 Histoplasmosis was considered 

Characteristics of individuals with fungal 

cause of death listed for the period 1970-

2012 (N=216) in the US Air Force Mortality Registry.

Variable n %N

Gender

Male 211 97.69

Female 4 1.85

Unknown 1 0.46

Age Group

20-44 years 18 8.33

45-54 years 16 7.41

55-69 years 50 23.15

65 years and older 135 61.11

Race

White 167 77.31

Black 32 14.81

Hispanic 4 1.85

Unknown 13 6.02

Underlying Cause of Death

Aspergillosis 36 16.67

Blastomycosis 4 1.85

Candida 43 19.91

Coccidioidomycosis 32 14.81

Cryptococcosis 12 5.56

Histoplasmosis 12 5.56

Mucormycosis/Zygomycosis 7 3.24

Pneumocystosis 25 11.57

Sporotrichosis 2 0.93

Unspecified mycosis 43 19.91

Duty Status

Active Duty/Active Reserve 8 3.70

Retiree 208 96.29
40 http://www.cs.amedd.army.mil/amedd_journal.aspx

among the top 3 fungal diseases among Medicare recipients, with the highest mortality.11

Within our study period, we record 12 fatalities from 

histoplasmosis. Ninety-one percent of the fatalities were 

male. A 25-year-old woman serving as a USAF reservist 

was among the fatalities for histoplasmosis, as well as a 

37-year-old active duty Airman. These deaths occurred 

in 1990 and 1991, respectively. The remaining 10 were 

male retirees aged from 62 to 89 years. The deaths occurred from 1971 to 2007, with 3 deaths in 1993. Proportionate mortality ratios for histoplasmosis as 1.2 from 

1970-20101

, indicating little to no difference between 

United States and Air Force proportionate mortalities. 

Hence, with the exception of the 2 individuals on active 

duty, the cases in retirees were predictable.

Mucormycosis/Zygomycosis: These diseases are 

caused by myriad species of Mucomycetes. We combined mucormycosis and zygomycosis deaths since they 

are both diseases caused by the same group of fungi. 

There are 7 records in the AFMR reporting mucormycosis/zygomycosis as the underlying cause of death. This 

is the second most common fungal disease in immunocompromised patients, but some opportunistic species infect immunocompetent hosts.12,13 Unlike many 

of the fungal disease where a single or limited number 

of pathogens are known, mucormycosis is caused by a 

wide range of pathogens and thus has a wide geographic 

reach. A 27-year-old male active duty member was recorded with mucormycosis/zygomycosis as underlying 

cause of death. Seventy-one percent of cases occurred 

in the 1980s.

Pneumocystosis: Pneumocystosis is caused by Pneumocystis jirovecii or a related Pneumocystis spp.1 Pneumocystis was described as a protozoan in older literature.14

Pneumocystosis is rarely detected in healthy people, 

but up to approximately 70% of HIV-infected people 

have P jirovecii in their respiratory tract.15 Almost all 

of the cases of pneumocystosis are in individuals with 

AIDS or with long-term immunosuppression. Pneumocystis pneumonia (PCP) was the defining opportunistic 

disease for two-thirds of AIDS patients in the United 

States during the onset of the AIDS pandemic.15 The 

PCP-related fatalities in the USAF are consistent with 

the trends for the AIDS pandemic. Approximately onethird of deaths occurred in each decade. The first 2 pneumocystosis deaths in our study were reported in 1986, 

and there were 7 deaths total in that decade. There were 

25 deaths in patients ranging in age from 35 to 80 years. 

The majority of deaths (n=13) occurred in the 1990s, 

with 5 deaths recorded since 2000. The most recently recorded pneumocystosis death in the AFMR was in 2012. 

Advances in antiretroviral drugs have greatly extended 

the lifespan and health of individuals infected with HIV. 

There were no female deaths recorded for pneumocystosis. All subjects with this underlying cause of death in 

our review were retired.

Sporotrichosis: This disease is caused by Sporothrix 

schenckii, and most infections are opportunistic, selflimiting, and cutaneous.16 The primary route of infection is through cuts from fungus-contaminated wires, 

thorns, needles, etc. Among the fungal causes of death 

in the AFMR, sporotrichosis was the least common. 

Two deaths of retirees were recorded, with one disseminated infection and one that was unspecified in terms 

of body organ/region affected. Both men were aged in 

their 60s. Additional information was not available, but 

presumably they had compromised immune systems.

Unspecified Mycosis: Unspecified mycosis tied with 

candidiasis for the greatest number of deaths. While we 

do not have enough information on the deceased, a specific fungal agent was not investigated postmortem. Unspecified mycosis deaths contribute almost 20% of our 

data, with 43 deaths. The death of a 52-year-old male active duty member resulted from an unspecified mycosis; 

the remainder were retirees. Two of the 4 women in our 

review died from unspecified mycosis.

Based on the death records, the threat of fungal diseases 

to active duty Airmen is very low, and fatal cases are 

extremely rare. Women die less frequently from fungal 

infections, but are a smaller component of the military 

overall.

Acknowledgments

We thank James Escobar and the AFMR staff for their 

assistance with database access. The views expressed in 

this article are those of the authors and do not necessarily 

reflect the official policy or position of the Air Force, the 

Department of Defense, or the US Government. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2014-5129, 5 Nov 2014.

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Authors

When this article was written, Mr Kugblenu was an Oak 

Ridge Institute for Science and Education Fellow, Public Health and Preventive Medicine Department, US Air 

Force School of Aerospace Medicine, Wright-Patterson 

Air Force Base, OH. He is now a Research Scientist 2 

with the New York State Department of Health, Albany, 

NY.

When this article was written, Dr Reeves was with the 

Public Health and Preventive Medicine Department, US 

Air Force School of Aerospace Medicine, Wright-Patterson Air Force Base, OH. Currently he is a Regulatory 

Analyst, Western Compliance Assurance Branch, Animal and Plant Health Inspection Service, US Department 

of Agriculture, Fort Collins, CO.
42 http://www.cs.amedd.army.mil/amedd_journal.aspx

Branches of the US armed forces provide public health 

support through preventive medicine services that reflect the public health organization within the civilian 

sector. Military operations can be significantly degraded by infectious diseases of many types, including acute 

gastrointestinal (GI) illness outbreaks. Due to the nature 

of military operations and the requirement for sleeping, 

feeding and personal hygiene activities and facilities, 

service members are often at a high risk for rapid GI 

outbreaks.1

 George Washington, with one of his first 

general orders, required all of his officers to ensure all 

service members under them maintained themselves in 

a neat and clean manner and to stress to them the importance of hygiene to their overall health and ability to 

serve. The importance of preventive medicine continued 

to be discussed in subsequent years. In 1818, Dr Joseph 

Lovell was appointed the first Surgeon General of the 

newly created Army Medical Department. In the year 

prior to his appointment, Dr Lovell communicated to 

other physicians the need for an emphasis on the investigation of the causes of disease and on the implementation of preventive measures based upon knowledge, or 

ideas, of the causes of these diseases.2

While knowledge regarding the effects of disease on war 

fighting increased, disease and nonbattle injuries continued to be a major cause of mortality and morbidity 

in the US Army. During the Mexican War (1846-1848) 

the ratio of nonbattle to battle deaths was almost 7:1.2

To help combat the effects of disease on military preparedness, 2 new divisions within the Surgeon’s Office 

were developed: the Division of Sanitation and the Division of Infectious Diseases and Laboratories. By 1917, it 

was evident that a new category of officer was needed to 

support sanitation efforts in the Army. By presidential 

authority, the Act of May 18, 1917, created a sanitary 

corps of reserve officers with specialties outside of those 

typically considered medical professionals. This act effectively created the Reserve Medical Corps which led 

to the creation of the Medical Service Corps. From this 

point on, officers with specialties in epidemiology, sanitation, and other related fields were tasked with monitoring issues related to disease prevention.2

Initially, preventive medicine was mostly concerned 

with the prevention of disease and nonbattle injuries 

through enforcement of basic hygiene practices, food 

service sanitation and inspections, and vector control. 

This was the standard doctrine through at least the Cold 

War era. However, the Department of Defense formalized its efforts to collect environmental samples and other exposure data because of issues related to Agent Orange exposure during the Vietnam conflict and the lack 

of good exposure data for all the chemical agents and 

vaccines suspected of causing veterans’ health problems 

after the Gulf War. To that end, preventive medicine 

was expanded in the late 1990s to include medical surveillance, specifically environmental and occupational 

Does Reducing Time to Identification of

 Infectious Agents Reduce Incidence Rates

 of Norovirus in a Population Deployed to

 Southwest Asia?

LTC Kip R. Thompson, MS, USAR

MAJ Eric C. Mossel, MS, USAR

Belle Federman, ScD

CDR (Ret) David M. Claborn, MSC, USN

Abstract

During its deployment to Kuwait from 2011-2012, the 983rd Medical Detachment (Preventive Medicine) was 

augmented with a 4-person laboratory section which provided polymerase chain reaction capabilities not normally associated with an Army Level III preventive medicine detachment. Although common in many civilian 

laboratories, this was the first time this equipment was used by a deployed Level III Army preventive medicine 

detachment to identify an outbreak in this theater—it allowed rapid identification and description of a gastrointestinal disease outbreak caused by norovirus in Kuwait. The technology contributed to a decreased time 

required to identification of the causative agent (hours vs days) and thus the implementation of appropriate 

preventive measures. Based on this event, the authors suggest the addition of a modified laboratory section to 

the modified table of organization equipment for deployable preventive medicine detachments.
October – December 2016 43

The Army Medical Department Journal

exposure assessments.3 Preventive medicine detachments historically were separated into 2 types: sanitation 

detachments and entomological detachments. However, 

the Army Medical Department recently began a reengineering initiative which redefined the roles of preventive 

medicine. With the implementation of the reengineering, all preventive medicine functions were consolidated 

into one functional detachment type.3

 With this reorganization, the capabilities of the 2 detachment types were 

merged, providing more robust services (Table 1).

Preventive medicine within the modern medical framework provides support at multiple levels. At the lowest 

level (Level I), individual service members and units 

are responsible for ensuring basic hygiene practices are 

followed to ensure health. Included in this level is the 

field sanitation team (FST), typically comprised of 2 to 

4 personnel. Each company-sized element is required to 

have trained FST personnel trained by preventive medicine technicians and officers. Level II support is typically provided by one preventive medicine officer (AOC* 

72D) and one preventive medicine technician (MOS* 

68S). This support is usually at the brigade, division, or 

corps level. These personnel are responsible for ensuring support at Level I is adequate and functional. This 

is the first level at which preventive medicine personnel perform this function. At Level III is the Medical 

Detachment, Preventive Medicine (PM). The standard 

operational capabilities are listed in Table 1. Most deployable PM detachments follow a prescribed manning 

document. Based on the table of organization and equipment† (TOE), a fully manned PM detachment currently 

has 12 personnel. The specialties include one environmental science and engineering officer (AOC 72D), one 

entomologist (AOC 72B) and 10 preventive medicine 

technicians (MOS 68S). Lab capabilities are present 

with Level IV. Lab services at this level are provided by 

the Area Medical Laboratory (AML). The AML is the 

theater laboratory for confirmation of suspected disease 

agents identified by the Level III detachment. The AML 

is also responsible for shipping samples to laboratories 

in the United States. The AML is composed of 3 sections providing support to specific areas. These sections 

are (1) the endemic disease section, (2) the occupational 

and environmental health section, and (3) the nuclear, 

biological and chemical weapons section. These services are not typically provided by a Level III medical 

detachment. The final level of support is Level V which 

is provided by preventive medicine units in the United 

States. Support is also provided by the proponent agency for preventive medicine issues, the US Army Public 

Health Center (APHC). Definitive laboratory services 

are provided by the APHC.4

Within this framework, modern preventive medicine 

detachments, when deployed, address issues similar to 

those of their civilian counterparts. As level III support, 

PM units are very limited in their laboratory capacity, 

with most tests being for the presence or absence of 

pathogens, particularly in potable water. However, during any suspected disease outbreak, stool, food, water, 

tissue, or other samples are collected and submitted to 

the nearest Level IV or V facility. This causes long delays in testing and obtaining subsequent results, with 

typical turnaround times ranging from 8 to 21 days.5,6

These delays lead to delays in implementation of control measures and may increase the incidence of cases. 

Also important, the potential for mission degradation 

is increased. The purpose of the present study was to 

determine if access to rapid real time PCR diagnostic 

capability at the detachment level, as described below, 

provided a diagnostic benefit to a deployed PM unit by 

reducing the time to identification of a causative agent 

and subsequent reductions in the incidence of GI illness 

compared to camps without such diagnostic capability.

983rd Medical Detachment (PM) Deployed

Capabilities

On September 19, 2011, the 983rd Medical Detachment (PM) (MED DET (PM)), a US Army Reserve unit 

based at Fort Snelling, MN, was activated in support of 

*AOC indicates area of concentration, MOS indicates military 

occupational specialty, both of which are medical skill designators.

†Table of Organization and Equipment: Defines the structure and 

equipment for a military organization or unit.

Table 1. Preventive Medicine Capabilities following the Army 

Medical Reengineering Initiative. Adapted from Army Regulation 40-5 and Bosetti.3,4

Medical Detachment, Preventive Medicine (Current)

Mission Provide preventive medicine support and 

consultation in the areas of entomology, 

DNBI prevention, field sanitation, sanitary 

engineering and epidemiology to minimize 

the effects of vector borne diseases, enteric diseases, environmental injuries, and 

other health threats to deployed US forces 

and their allies.

Basis of Allocation 1 Detachment per 17,000 personnel.

Assignment Assigned to a medical brigade or a medical 

group, and normally attached to an area 

support medical battalion or theater medical command.

Mobility Unit is 100% mobile for all personnel and 

equipment in a single lift using its authorized organic vehicles.

Capabilities Provides surveillance and control of disease 

vectors and reservoirs in assigned areas, 

including area and aerial spraying. Collected samples are forwarded to the nearest 

Level IV or Level V facility.
44 http://www.cs.amedd.army.mil/amedd_journal.aspx

Operation Enduring Freedom ongoing in Kuwait. As previously mentioned, a typical detachment is comprised of 

12 personnel with training in preventive medicine and 

one wheeled vehicle mechanic. However, for this mobilization, the deployment manning document was adjusted to provide enhanced capabilities. The detachment 

deployed 2 environmental science and engineering officers (AOC 72D), one entomologist (AOC 72B), one microbiologist (AOC 71A), one biochemist (AOC 71B), one 

preventive medicine physician (AOC 60C), 7 preventive 

medicine technicians (MOS 68S), 

and 2 laboratory technicians (MOS 

68K), as shown in Table 2.

Corresponding with the additional 

personnel, the equipment inventory 

was augmented to include standard 

preventive medicine equipment 

and laboratory equipment. The additional equipment and personnel 

were intended to enhance diagnostic capabilities to the level typically 

found at the AML (Level IV) and 

at medical facilities in the United 

States (Level V). For example, nuclear, chemical and biological detection capabilities were increased 

by the addition of a hazardous 

material identification and hazardous air pollutant onsite gas chromatograph mass spectrophotometers (used for the identification of 

chemical hazards), identiFINDER 

radio-nucleotide monitors (FLIR 

Systems, Inc, Wilsonville, OR) and the Joint Biological 

Agent Identification and Diagnostic System (JBAIDS), 

which uses polymerase chain reaction technology for the 

identification of suspected biological warfare agents including those that cause anthrax, brucellosis, tularemia, 

and others (Table 3). Additionally, the provided equipment set included an Applied Biosystems Incorporated 

(Carlsbad CA) Model 7500 Fast Real-Time Polymerase 

Chain Reaction System (ABI 7500 FRT PCR). With 

the addition of the ABI 7500, the laboratory section of 

the 983rd MED DET (PM) was 

tasked with analyzing and typing 

suspected influenza samples collected from personnel presenting at 

the troop medical clinics. This data 

was used in the Department of Defense Global Emerging Infections 

Surveillance and Response System 

(DoD-GEIS) to globally track influenza subtypes and their effects 

on US military personnel. Labconfirmed specimen results were 

coupled with demographic data 

and shared electronically on the 

GEIS web-based reporting systems. 

Initially, the ABI 7500 was used exclusively to analyze influenza samples for the DoD-GEIS program. 

However, it was soon realized that 

as a real-time PCR system, the ABI 

7500 system had many advantages 

in laboratory confirmation and 

might be used in a broader mission, 

particularly monitoring for disease 

Table 2. Comparison of Standard and Enhanced Preventive Medicine Capabilities for the 983rd MED DET (PM).

Standard MTOE

Personnel (AOC/MOS)*

Enhanced MTOE(+)

Personnel (AOC/MOS)*

Proposed MTOE

Personnel(AOC/MOS)*

Environmental Science Officer (72D) Environmental Science Officer (72D) Environmental Science Officer (72D)

Entomologist (72B) Environmental Science Officer (72D) Entomologist (72B)

Detachment Sergeant (68S) Entomologist (72B) Microbiologist (71A)

Preventive Medicine NCO (68S) Microbiologist (71A) Detachment Sergeant (68S)

Preventive Medicine NCO (68S) Biochemist (71B) Preventive Medicine NCO (68S)

Preventive Medicine NCO (68S) Preventive Medicine Physician (60C) Preventive Medicine NCO (68S)

Preventive Medicine NCO (68S) Detachment Sergeant (68S) Preventive Medicine NCO (68S)

Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S)

Preventive Medicine NCO (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S)

Preventive Specialist (68S) Preventive Medicine NCO (68S) Preventive Medicine NCO (68S)

Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S)

Preventive Specialist (68S) Preventive Specialist (68S) Preventive Specialist (68S)

Preventive Specialist (68S) Preventive Specialist (68S)

Laboratory Technician (68K) Laboratory Technician (68K)

Laboratory Technician (68K)

*MTOE – modified table of organization and equipment

AOC – area of concentration

MOS – military occupational specialty

Table 3. Initial Diagnostic Capabilities Using 

the JBAIDS and ABI 7500 Systems as of 

October 20, 2011.

Target System

Bacillus anthracis T1 JBAIDS

Bacillus anthracis T2 JBAIDS

Brucella JBAIDS

Burkholderia JBAIDS

Coxiella burnetii JBAIDS

Eastern equine encephalitis virus JBAIDS

Francisella tularensis JBAIDS

Influenza virus A and B JBAIDS

Influenza virus A SUBTYPING (H) JBAIDS

Orthopox Viruses JBAIDS

Rickettsia prowazekii JBAIDS

Variola virus JBAIDS

Venezuela equine encephalitis virus JBAIDS

Western equine encephalitis virus JBAIDS

Yersinia pestis T1 JBAIDS

Yersinia pestis T2 JBAIDS

Influenza virus A and B ABI 7500

Influenza virus A SUBTYPING (H) ABI 7500

Norovirus SEROGROUP 1 ABI 7500

Norovirus SEROGROUP 2 ABI 7500

Does Reducing Time to Identification of Infectious Agents Reduce

Incidence Rates of Norovirus in a Population Deployed to Southwest Asia?
October – December 2016 45

The Army Medical Department Journal

outbreaks, including gastroenteritis. At this time, the 983rd requested funds to purchase primer sets to 

expand the diagnostic capabilities 

of the ABI 7500 system to include 

many of the more common infectious agents related to gastrointestinal outbreaks (Table 4).

Based on the normal protocol for 

preventive medicine services, a 

Level III PM detachment would 

collect samples and send them to 

a Level IV or Level V lab for diagnosis and confirmation. For example, if a suspected food borne 

illness outbreak were to occur, the 

environmental science and engineering officer, in conjunction with 

PM technicians, would initiate a 

foodborne illness investigation. 

Because of the distance from these 

labs and the customs procedures 

for shipping biological samples, it 

took 2 or 3 weeks for results to be 

released. Due to the length of this 

delay, PM personnel were often 

left guessing as to the controls and 

steps which should have been implemented to address the outbreak. 

However, from start to finish, the 

typical turnaround time for a sample analyzed using the ABI 7500 is 

4 to 6 hours. This drastic reduction 

in the time needed to identify the 

causative agent using the ABI 7500 

system allowed members of the 

983rd MED DET (PM) to implement control measures 

within 24 to 48 hours, thereby reducing the incidence 

and burden on the norovirus outbreak on service members in Kuwait during November, 2011 (Figure 1). The 

results and outcome of the usefulness of the enhanced 

capabilities of the 983rd MED DET (PM) in controlling 

the norovirus outbreak are reported below.

Materials and Methods

Daily, routine monitoring of reported disease nonbattle 

injury (DNBI) was conducted through the Medical Situational Assessment Tool (MSAT) data base and the Joint 

Medical Workstation (JMeWS). The MSAT system is a 

theatre level application that combines information from 

multiple reporting locations throughout a defined area 

of responsibility. Data is reported by providers for individual encounters through the Medical Communications 

for Combat Casualty Care computer 

system. The JMeWS is a theater 

medical surveillance system which 

integrates health related information from all branches of the US 

military (Army, Navy, Air Force, 

and Marine Corps). Illnesses are 

coded using ICD-9* codes. During monitoring of these systems, all 

ICD-9 558 codes were reviewed 

and analyzed for gastrointestinal GI 

encounters reported by the provider. 

During suspected GI outbreaks in 

Kuwait and Iraq, suspected cases 

were defined as individuals reporting with nausea, diarrhea, or stomach cramps. Confirmation for cases 

in Kuwait was defined as those 

cases with the above symptoms as 

well as laboratory confirmation using real-time PCR via the ABI 7500 

system by the laboratory component of the 983rd MED DET (PM). 

However, confirmation of cases in 

Iraq was defined as those cases with 

the above symptoms with laboratory confirmation conducted by laboratory personnel at Landstuhl Regional Medical Center, Landstuhl, 

Germany.

Concurrent with monitoring of 

digital reporting systems, members of the 983rd MED DET (PM) 

also monitored the use of over the 

counter medications (OTC) either 

provided for free from the pharmacies located at Camp Arifjan or Camp Beuhring, or 

purchased by personnel from the Post Exchange. During the suspected GI outbreak, pharmacy technicians at 

each camp in Kuwait provided a daily Excel spreadsheet 

showing the number of requests of OTC medications, 

specifically antidiarrheals such as Loperamide. Post Exchange personnel in Kuwait provided daily point of sale 

totals from each location for similar medications, such 

as Loperamide and Pepto Bismol.

Statistical analyses to compare disease rates between 

camps were conducted using SPSS and Excel statistical 

software packages. Chi-squares tests were performed 

to assess the similarity of the camp populations as described by age, class and sex. Chi-square tests were 

also performed to test for difference in daily incidence 

Table 4. Enhanced Diagnostic Capabilities 

Using the JBAIDS and ABI 7500 Systems as 

of April 20, 2012.

Target System

Bacillus anthracis T1 JBAIDS

Bacillus anthracis T2 JBAIDS

Brucella JBAIDS

Burkholderia JBAIDS

Coxiella burnetii JBAIDS

Eastern equine encephalitis virus JBAIDS

Francisella tularensis JBAIDS

Influenza virus A and B JBAIDS

Influenza virus A SUBTYPING (H) JBAIDS

Orthopox Viruses JBAIDS

Rickettsia prowazekii JBAIDS

Variola virus JBAIDS

Venezuela equine encephalitis virus JBAIDS

Western equine encephalitis virus JBAIDS

Yersinia pestis T1 JBAIDS

Yersinia pestis T2 JBAIDS

Influenza virus A and B ABI 7500

Influenza virus A SUBTYPING (H)

(DoD-GEIS Project)

ABI 7500

Norovirus SEROGROUP 1 ABI 7500

Norovirus SEROGROUP 2 ABI 7500

Salmonella enterica ABI 7500

Giardia lamblia and G duodenalis ABI 7500

Campylobacter jejuni ABI 7500

Shigella flexneri ABI 7500

Yersenia enterolytica ABI 7500

Clostridium difficile ABI 7500

Vibrio cholerae ABI 7500

V parahaemolyticus ABI 7500

V vulnificus ABI 7500

Legionella ABI 7500

Influenza virus A N1 subtyping ABI 7500

Influenza virus A N2 subtyping ABI 7500

Influenza virus 2009 N1 subtyping ABI 7500

*International Classification of Diseases, 9th Revision
46 http://www.cs.amedd.army.mil/amedd_journal.aspx

between camps. Additionally, ANOVA with least significant difference comparisons were conducted to compare mean incidence baseline and daily rates between 

the 3 camps. Attributable risk was calculated between 

Kuwait and Iraq camps to estimate the potential effect 

that camp location (and therefore access to rapid diagnostic testing) might have on outcomes.

Results

Based on χ2 analyses, there was no difference in the makeup of camps by age 

or sex (Table 4). This is to be expected 

since military populations tend to be 

more homogenous than civilian populations. From November 1st through November 9th, the number of reported cases 

(suspected and confirmed) in Kuwait 

increased from a normal base level of 1 

to 2 per day to a maximum of 18 on November 4. In Camp Adder, Iraq, a GI outbreak was documented from November 

13 through November 19, 2011 (Figure 2).

Approximately 300 personnel located in 

Kuwait presented to sick call with acute 

gastroenteritis with symptoms which included nausea, prolonged watery stool, 

mild fever, and general malaise. Of those, 

127 cases were reported at Camp Buehring and 88 cases were reported at Camp 

Arifjan. All others were from other camps 

located in Kuwait. Of all cases reported, 

6 were confirmed through real-time PCR. 

During the documented outbreak in 

Camp Adder, 130 personnel reported to sick call with 

acute GI symptoms. Typical daily incidence rates for 

reported GI cases ranged from 0.00 to 0.76 per 1,000 

personnel (CI±0.06) for Camp Buehring, 0.00 to 0.47 

per 1,000 (CI±0.04) for Camp Arifjan and 0.00 to 0.67 

per 1,000 (CI±0.07) for Camp Adder (Figure 3). These 

baseline rates were not significantly different (P=.63). 

During each outbreak, incidence rates increased rapidly 

(Figure 3). Based on a 7-day comparison during each 

outbreak, incidence rates for 6 of the 7 outbreak days 

were significantly higher at Camp Adder than at Camps 

Arifjan and Beuhring in Kuwait (all P<.02) (Figure 4). 

Camp Arifjan and Camp Beuhring incident rates were 

not significantly different (Table 2). Additionally, during 

the reported outbreak, a sharp increase in the request 

and use of medications specifically for gastrointestinal disorders was noted (Figure 5). The increase in the 

use of OTC medication corresponded with increases in 

reported GI cases through daily DNBI monitoring. At 

peak use, the distribution of OTC medications was significantly higher than the baseline (P<.001).

To determine what effect the utilization of the laboratory 

in Kuwait might have had on the incidence of norovirus 

in Kuwait and Iraq, attributable risk was a calculated. 

For these calculations, exposure was assigned to camps 

Camp

Beuhring

Camp

Adder

Camp

Arifjan

Figure 1. Map of generalized locations of US encampments 

of interest in Kuwait and Iraq, November 2011.

Figure 2. Number of cases reporting to sick call with GI complaints for the period 

October 22, 2011, through November 21, 2011. The clinics are not open on Sundays, which caused an apparent decline in the number of personnel reporting for 

November 6 and November 13. Cases overall were significantly different between 

camps (P<.001); however, only Camp Adder was significantly different when compared to Camps Arifjan and Beuhring (P<.003).

21 23 25 27 29 31 2 4 6 8 10 12 14 16 18 20

October 2011 November 2011

Camp Arifjan

Camp Beuhring

Camp Adder

Date

Reported 

GI Cases

35

0

5

20

30

15

25

10

Does Reducing Time to Identification of Infectious Agents Reduce

Incidence Rates of Norovirus in a Population Deployed to Southwest Asia?
October – December 2016 47

The Army Medical Department Journal

in Kuwait where rapid laboratory identification was available. Iraq, where any stool 

or food sample had to be shipped and analyzed by normal protocols, was set as unexposed because it did not have the rapid 

diagnostic capability. Attributable risk was 

calculated as 0.664 indicating that 66.4% 

of all cases of norovirus in Iraq could be 

attributed to the lack of rapid laboratory 

diagnostic services and subsequent delay 

in the implementation of controls (Table 5).

Comment

Norovirus is a nonenveloped, positive sense, 

single stranded RNA virus which can cause 

acute gastroenteritis in humans. The virus 

is responsible for the GI outbreaks noted 

on cruise ships and in other areas where 

humans are densely located. Outbreaks in 

military settings have also been reported 

in Iraq, Afghanistan, and aboard naval vessels.5

 The virus is highly contagious and 

can cause symptomatic reactions with an 

exposure dose as low as 100 viral particles. 

The primary route is fecal-oral, either by 

person-to- person contact or through indirect contact via surface contact with contaminated food, water or fomites.6

 It can also 

be spread through aerosolized particles produced via vomiting. The virus is relatively 

stable and has been known to persist in the 

environment for several days. The average 

incubation period is 12 to 48 hours. Symptoms include acute-onset vomiting, watery 

nonbloody stool, headache, low grade fever, 

and general malaise.1

 Symptoms can persist 

for 24 to 60 hours and reinfection can occur. 

A person can be asymptomatic but still be 

infectious through shedding of viral particles. Additionally, infections with norovirus 

do not confer any lasting immunity. While 

often self-limiting, norovirus outbreaks can 

persist with conditions typically found in 

military settings, especially when service 

members are deployed. Camp Arifjan and 

Camp Buehring were mostly populated with 

service members assigned to units mobilized to Kuwait for 9 to 12 months. Members assigned to these units typically were 

housed together in discrete areas of the camps. However, 

with the influx of personnel during the movement out of 

Iraq, personnel from different units were comingled and 

housed where space allowed. This made it difficult to determine a specific index case or any trends in incidence 

of norovirus caused illness by unit. As the number of 

personnel increased, the fixed facilities of each camp 

quickly became inadequate for the number of personnel present. For example, ideally each service member 

is allocated at least 72 square feet of living space. At 

Figure 4. Reported daily incidence per 1,000 service members aligned by peak 

incidence per camp. Daily incidence at Camp Adder were significantly different 

than daily incidence at the other 2 camps (P<.02). Daily Incidence

Day of Outbreak

-5 -4 -3 -2 -1 0 1 2 3 4 5

7

0

1

4

6

3

5

2

Camp Arifjan

Camp Beuhring

Camp Adder

Figure 3. Reported daily incidence per 1,000 service members for the period 

October 22, 2011, through November 21, 2011. Daily incidence at Camp Adder 

were significantly different than daily incidence at the other 2 camps (P<.02).

Date

October 2011 November 2011

Daily Incidence

7

0

1

4

6

3

5

2

Camp Arifjan

Camp Beuhring

Camp Adder

23 25 27 29 31 2 4 6 8 10 12 14 16 18 20 22
48 http://www.cs.amedd.army.mil/amedd_journal.aspx

the height of troop densities, most service members on 

Camp Buehring were allocated 36 to 40 square feet of 

living space. Concurrently, the ratio of latrines and hand 

washing sinks available for use on Camp Buehring went 

from 1 for every 10 personnel to 1 for every 30 personnel. 

Initially, cleaning contracts were not amended, resulting 

in latrines being cleaned only twice per day (every 12 

hours). Within 4 or 5 hours of a cleaning cycle, most latrines were overflowing, and had no soap, water, or hand 

sanitizer available. Also, during this time, there was only 

one dining facility (DFAC) open resulting in long lines. 

Prior to entering any DFAC, personnel were required to 

wash their hands. However, because the lines were so long, only 

20% to 30% of the personnel entering the DFAC were observed 

washing their hands. Within the 

DFAC, the fruit and salad bar and 

drink dispensers were self-serve 

operations. Because personnel 

were not washing their hands after 

using the latrine or when they entered the DFAC, the utensils used 

to serve salads and fruit and cups 

on the drink serving line became 

excellent sources for transmitting the virus. The door handles 

entering the DFAC were also potential 

sources for hand-to-mouth transmission of the disease.

Rapid identification of norovirus as 

the causative agent by real-time PCR 

in the 983rd MED DET (PM) Infectious Disease Lab allowed for a rapid 

response to the outbreak. Primer sets 

for norovirus were included in the 

turnover of the ABI 7500, and were 

thus already part of the 983rd’s laboratory capabilities, which allowed positive confirmation of norovirus type 1 

within 6 hours of receipt of the first 

stool specimen. Because neither the 

troop medical clinic nor hospital laboratories possessed diagnostic capabilities for norovirus, any stool samples 

collected from either laboratory would 

normally be sent to Landsthul Regional Medical Center (LRMC) in Germany for analysis. The typical turnaround 

time for results from LRMC was one 

to two weeks. By using the ABI 7500, 

the time for confirmation was reduced 

from weeks to hours (Table 6).

Once confirmation occurred, the 983rd MED DET (PM) 

implemented specific controls that reduced the scope 

and magnitude of the outbreak. Strict hand washing 

protocols were implemented which included observing all personnel entering any food establishment. If 

personnel did not wash their hands prior to entry, they 

were denied access to rations and were given a counseling statement which was added to their records. Random checks of hand washing after latrine use were also 

done. Concurrently, in coordination with public affairs 

personnel of US Central Command (CENTCOM), the 

Figure 5. Number of requests for over-the-counter bottles of the antidiarrheal drug 

Loperamide given through the Camp Arifjan pharmacy. Results are tabulated weekly. 

Requests for Loperamide began to increase the week of October 8, approximately 3 

weeks prior to documented increases in the number sick calls for acute GI complaints. 

Peak requests were significantly greater than baseline requests (P<.001).

1 Oct 8 Oct 15 Oct 22 Oct 29 Oct 5 Nov 12 Nov 19 Nov 26 Nov 3 Dec

Number of Requests for OTC Loperamide

40

50

0

30

60

20

90

70

10

80

Day of Month (2011)

Table 5. Distributions by age and sex are similar across all camps and to the overall 

Army-wide values. No significant difference in age by class or gender distribution occurred among the 3 camps.

Patient Age

(Years)

Camp Arifjan

(Kuwait)

Camp Bheuring

(Kuwait)

Camp Adder

(Iraq)

Cumulative Army-wide

≤25 41.2% 42.7% 43.0% 42.3% 42.7%

26-30 23.0% 23.2% 22.7% 22.7% 23.0%

31-35 13.7% 14.6% 14.6% 14.6% 14.7%

36-40 10.3% 9.8% 10.5% 10.5% 10.6%

≥41 10.9% 9.7% 9.3% 9.9% 9.1%

Patient Gender n=117 n=82 n=128 N=327 N=1,105,301*

Male 85.5% 84.1% 85.2% 85% 85.4%

Female 14.5% 15.9% 14.8% 15% 14.6%

*Includes Active, Reserve, and National Guard components.

Does Reducing Time to Identification of Infectious Agents Reduce

Incidence Rates of Norovirus in a Population Deployed to Southwest Asia?
October – December 2016 49

The Army Medical Department Journal

983rd MED DET (PM) Command produced a public 

service announcement on the outbreak and the need for 

proper hand washing and hygiene. Contracted cleaning 

staffs were trained on the use of a chlorine solution for 

sanitation of all bathroom surfaces. This sanitation occurred at least 3 times per day. Through dissemination 

of strict hand washing requirements via public service 

announcements, the outbreak was limited in the number 

of personnel affected, resulting in fewer days lost and 

no loss in mission capability.

The number of affected personnel in Kuwait was kept to 

approximately 2.2% of the total population at the time 

and the duration of the outbreak was less than 2 weeks 

(Figure 3). While the duration of the outbreak was approximately 3 days longer than the outbreak in Camp Adder, the number of affected personnel on any one camp in 

Kuwait was less than the number affected on Camp Adder. Additionally, the daily incidence rate for reported GI 

patients was less for camps in Kuwait compared to Camp 

Adder. Similar outbreaks in other theatres of operation 

also affected a greater percentage of the total population. 

For example, an outbreak in Qatar resulted in approximately 300 personnel contracting the virus out of a total 

camp population of 1,250. All 

changes in protocols and enforcement which mitigated the 

outbreak were a direct result of 

the rapid identification of norovirus as a causative agent.

Ultimately, laboratories are 

the cornerstone of disease 

diagnosis for public health. 

Routine patient testing is now 

largely performed by clinical 

laboratories; however, the results of these tests are needed 

by public health for surveillance, outbreak investigations, 

and disease control. This is a 

core function of public health 

laboratories. This core function requires accurate and 

timely data. To improve the 

accuracy and timeliness of 

testing and reporting, clinical laboratories should work 

closely with public health laboratories, with each complementing the capabilities of the 

other.7

 Historically, laboratory 

testing for specific pathogens 

involved the use of clinical 

tests based on bacterial plating techniques or tests for 

specific toxins. Many of these tests, while cheap, required days to weeks to complete, extending the time 

for implementation of specific interventions designed to 

reduce or limit the disease burden.8,9 All of the steps 

necessary for investigation and reporting between onset of symptoms and a public health response delay the 

recognition of an outbreak and an appropriate response.

To effectively control disease outbreaks, it is critical that 

rapid detection occurs. Rapid detection of the causative 

agent allows for earlier containment. Paramount to this 

identification is the development and use of DNA/RNA 

and protein technology which give rapid, sensitive and 

accurate diagnoses on what microbe or virus is responsible. Real-time PCR systems have the potential to accurately and rapidly identify pathogenic organism not 

only by species, but also by the strain of the organism. 

The rapid detection and response by public health officials, whether military or civilian, to a suspected outbreak continues to be a major concern.10 Because the 

time to detection and identification is the most critical 

concern, real-time PCR has the potential to positively 

affect public health. Because real-time PCR systems 

Table 6. Comparison of typical versus enhanced laboratory timelines to confirmation of 

causative agent for typical GI outbreaks. Civilian and military timelines are similar when using 

the typical confirmation timeline. The timelines demonstrate that the availability of a laboratory 

capability embedded in a deployed PM detachment reduces the time required for confirmation 

from weeks to hours.

Typical timeline (days) for confirmation of causative agent for typical GI outbreaks following 

sample collection by a civilian clinic or health 

department facility.a

Timeline (hours) for confirmation of causative 

agent with laboratory capability embedded in 

deployed PM detachment.

Process Days (cumulative) 

to completion of 

process after collection of sample

Process Hours Required

Receipt of stool samples 2-4 Receipt of stool 

samples after collection by provider

1-2b

Results of initial stool 

sample culture

5-8 Molecular subtyping 4-6 (after receipt of 

sample)

Case report to health 

department

7-9 Positive confirmation 

of causative agent

5-30 (cumulative following sample collection, 

depending on time 

required for receipt)

Isolate submission to 

public health laboratory

8-10

Interview 12 for E coli

14 for Salmonella

18 for Campylobacter

Molecular subtyping 15 for E coli

18 for Salmonella

21 for Campylobacter

aClosely comparable to the 8-21 days typically 

required when samples gathered in deployed locations must be shipped to an Area Medical Laboratory or Army Public Health Center laboratories in 

either Landstuhl, Germany, or Aberdeen Proving 

Ground, Maryland.

b Time required if provider notifies PM of sample 

collection, and PM retrieves sample. Otherwise, 

it may require up to 24 hours for receipt.
50 http://www.cs.amedd.army.mil/amedd_journal.aspx

are able to produce results in as little as one hour, the 

speed at which a causative agent is identified is drastically reduced compared to classic laboratory diagnostic 

techniques (days to weeks).9

 In conjunction with enrichment techniques, real-time PCR has the potential to not 

only provide accurate, reliable, and quick diagnostics, 

but also quantification of the pathogen load when used 

to test foods for possible contamination.9

 This could provide even more data for the investigation of foodborne 

disease outbreaks. Critical to our ability to respond to 

disease outbreaks is the rapid and continual development of scientific technology. These advances will be the 

foundation for the response by public health to emerging 

and infectious disease outbreaks. For infectious diseases, 

applying genomics and proteomics to the determination 

of the disease source (causative agent) will be critical.11

The rapid and successful identification and mitigation of 

the Kuwait norovirus outbreak generated an appreciation 

for the potential utility of this system when integrated 

into the preventive medicine mission. With this in mind, 

a request was presented to CENTCOM to expand the 

diagnostic capabilities of the 983rd laboratory through 

the purchase of additional real-time PCR primer sets for 

known causative agents of gastroenteritis. Based on the 

results of the norovirus outbreak, CENTCOM agreed 

with the proposed expansion of diagnostic capabilities. 

Based on known or suspected agents of foodborne illnesses in Kuwait, the 983rd increased GI diagnostic capabilities by nearly 5-fold and overall diagnostic capability by almost 100% with minimal cost (approximately 

$3,000) (Table 4). These additional primer sets allowed 

for the identification of 5 additional pathogens associated with cases of GI illness in Kuwait. This expanded 

capability is unique for a forward deployed PM detachment, but has the potential to improve services provided 

in the deployed area of operations.

Real-time PCR is an important tool for forward deployed laboratories involved in disease monitoring and 

control. Two systems were available during this mobilization: JBAIDS and the ABI 7500. The JBAIDS has 

the advantage of portability and ambient reagent storage, 

but it also has the significant disadvantages of reagent 

cost, short shelf-life (6-12 months), and compatibility 

with only specific reagent kits. The ABI 7500 system, 

on the other hand, is not easily portable and requires 

some reagents to be stored cold or frozen, but such reagents are significantly less costly and may be stored 

frozen almost indefinitely. Also, the ABI 7500 may be 

adapted for a very large number of applications.

The success in controlling the norovirus outbreak, demonstrated by reduced incidence rates in Kuwait compared 

to Iraq, illustrates that the Army Medical Department 

should consider permanent changes to the deployable 

preventive medicine modified TOE to include a 2-person laboratory section and the ABI 7500 system with appropriate support equipment, reagents, and primer sets. 

This system has the potential to positively affect service 

member health and mission readiness while deployed by 

decreasing the time for diagnostic confirmation of many 

diseases of military importance.

References

1. Chapman AS, Witkop CT, Escobar JD, et al. Norovirus outbreak associated with person-to-person 

transmission, U.S. Air Force Academy, July 2011. 

MSMR. 2011;18(11):2-5.

2. Bayne-Jones S. The American Revolutionary War 

and first years of the republic (1775-1783; 1799). In: 

The Evolution of Preventive Medicine in the United States Army, 1607-1939 [internet]. Washington, 

DC: Office of Medical History, US Army Medical Department. 1968. Available at: http://history.

amedd.army.mil/booksdocs/misc/evprev/ch3.htm. 

Accessed June 7, 2016.

3. Bosetti T. Integrating Medical Surveillance into 

the Mission of the Medical Detachment (Preventive Medicine) [master’s thesis]. Fort Leavenworth, 

KS: US Army Command and General Staff College; 2002.

4. Army Regulation 40-5: Medical Services, Preventive Medicine. Washington, DC: US Department of 

the Army; 2007.

5. No authors listed. Historical perspective: norovirus 

gastroenteritis outbreaks in military forces. MSMR. 

2011;18(11):7-8.

6. Heyman DL, ed. Control of Communicable Diseases Manual. 18th ed. Washington, DC: American 

Public Health Association; 2004.

7. Downes FP, Ridderhoff JC. The evolving Public Health Laboratory System. Public Health Rep. 

2010;125(suppl 2):1-3.

8. Buehler JW, Berkelman RL, Hartley DM, Peters CJ.. 

Syndromic surveillance and bioterrorism-related 

epidemics. Emerg Infect Dis. 2003;9(10):1197-1204.

9. Lopez-Campos G, Martinez-Suarez JV, AguadoUrdez M, Lopez-Alonso V. Microarray Detection 

and Characterization of Bacterial Foodborne 

Pathogens. New York, NY: Springer; 2012.

10. Malorny B, Tassios PT, Rådström P, Cook N, Wagner M, Hoorfar J. Standardization of diagnostic 

PCR for the detection of foodborne pathogens. Int 

J Food Microbiol. 2003;83(1):39-48. DOI http://

dx.doi.org/10.1016/S0168-1605(02)00322-7.

Does Reducing Time to Identification of Infectious Agents Reduce

Incidence Rates of Norovirus in a Population Deployed to Southwest Asia?
October – December 2016 51

The Army Medical Department Journal

11. Malorny B, Paccassoni E, Fach P, Bunge C, Martin A, Helmuth R. Diagnostic real-time PCR for 

detection of Salmonella in food. Appl Environ 

Microbiol. 2004;70(12):7046-7052. DOI: 10.1128/

AEM.70.12.7046-7052.2004.

Authors

LTC Thompson is an Assistant Professor with the Master of Public Health Program, Missouri State University, 

Springfield, Missouri.

MAJ Mossel is a Microbiologist with the Virology Division, US Army Medical Research Institute of Infectious 

Diseases, Fort Detrick, Maryland.

Dr Federman is an Advanced Epidemiologist, Bureau of 

Health Promotion, Kansas Department of Health and Environment, Topeka, Kansas.

CDR (Ret) Claborn is an Associate Professor and Interim Director of the Master of Public Health Program, 

Missouri State University, Springfield, Missouri.
52 http://www.cs.amedd.army.mil/amedd_journal.aspx

Traumatic brain injury (TBI) is an invisible injury of 

war that has been identified as the “signature injury” 

of Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF).1-8 Between 2000 and 2015, the Department 

of Defense (DoD) diagnosed 333,169 cases of TBI in 

US service members worldwide across all services and 

duty statuses, with an estimated 20% of these diagnoses made in deployment settings. Approximately 82% 

of the total diagnoses during this period were classified 

as mild.9

 Common mechanisms of injury (MOI) for TBI 

experienced by military personnel are blast exposure or 

nonblast events, occurring either in isolation or combination. It is estimated that blast exposure is responsible 

for approximately 75% to 80% of all combat injuries 

in both OIF and OEF.10,11 Common deployment-related events that can result in blast-exposed TBI include 

the detonation of improvised explosive devices (IEDs), 

rocket propelled grenades (RPGs), vehicle borne improvised explosive devices (VBIEDs), and mortars; while 

common events that can result in a nonblast TBI include 

motor vehicle accidents, falls, assaults, rapid acceleration/deceleration, and sports/recreation training exercises.12,13 Multiple studies have shown a pattern of sensory 

impairments including hearing loss and/or tinnitus in 

the presence of mTBI.3,5,6,8,13-18

Service in the US military often exposes an individual 

to high-intensity and hazardous noise levels, which are 

known risk factors for both hearing loss and tinnitus. 

The Department of Veterans Health Administration has 

identified tinnitus and hearing loss as the number 1 and 

2 service connected disabilities, respectively, every Fiscal Year since 2007.19-25 Tinnitus is estimated to have a 

prevalence rate of 30.8% among Veterans of OIF, OEF, 

and Operation New Dawn (OND). While the estimated 

prevalence of hearing loss in Veterans of current conflicts is reported at 7.3 to 26.6%, an increase from 0.8% 

in 2003 and 2.2% between 2004-2009.10

Deployed service members are exposed to both military-unique and industrial noise hazards, which would 

warrant the use of a hearing protection device (HPD). 

Additionally, military personnel and the civilians who 

serve alongside them are frequently exposed to hazardous noise levels that are often higher than those measured in most industrial occupational environments.26

Examples of military unique noises include weapon 

systems, blast exposures, fixed- and rotary-wing aircraft, and tracked and wheeled vehicles, while common 

high intensity industrial noise hazards include sources 

such as power tools, generators, and/or machinery.26,27

Hearing Loss and Tinnitus in Military

 Personnel with Deployment-Related

 Mild Traumatic Brain Injury

Stephanie J. Karch, AuD, PhD Sridhar Krishnamurti, PhD

LTC José E. Capó-Aponte, SP, USA Robert N. Staton, AuD

LTC D. Scott McIlwain, SP, USA Kendra Jorgensen-Wagers, PhD

Michael Lo, MSPH

Abstract

The objective of this study was to analyze differences in incidence and epidemiologic risk factors for significant 

threshold shift (STS) and tinnitus in deployed military personnel diagnosed with mild traumatic brain injury 

(mTBI) due to either a blast exposure or nonblast head injury. A retrospective longitudinal cohort study of 

electronic health records of 500 military personnel (456 met inclusion criteria) diagnosed with deploymentrelated mTBI was completed. Chi-square tests and STS incidence rates were calculated to assess differences 

between blast-exposed and nonblast groups; relative risks and adjusted odds ratios of developing STS or tinnitus 

were calculated for risk factors. Risk factors included such characteristics as mechanism of injury, age, race, 

military occupational specialty, concurrent diagnosis of posttraumatic stress disorder (PTSD), and nicotine use. 

Among blast-exposed and nonblast patients, 67% and 58%, respectively, developed STS, (P=.06); 59% and 

40%, respectively, developed tinnitus (P<.001). Incidence of STS was 24% higher in the blast-exposed than 

nonblast group. Infantry service was associated with STS; Marine Corps service, PTSD, and zolpidem use were 

associated with tinnitus. Unprotected noise exposure was associated with both STS and tinnitus. This study 

highlights potential risk factors for STS and tinnitus among blast-exposed and nonblast mTBI patient groups.
October – December 2016 53

The Army Medical Department Journal

Hazardous noise exposures experienced in combat may 

exceed intensity levels against which the issued HPD 

can protect, and therefore still cause auditory damage 

even when the HPD is in use.28

Deployments with and without combat experience have 

been shown to have an association with injury to the ear 

and/or auditory system. Specifically, military deployment has been associated with acoustic trauma, permanent threshold shifts, tinnitus, tympanic membrane 

(TM) perforation, and/or an H3 to H4 hearing profile (ie, 

a moderate to profound hearing loss with aided speech 

reception thresholds greater than 30 dBHL (decibel 

hearing level)).28 Additionally, military deployment 

with combat experience has been shown to increase the 

likelihood of reporting hearing loss by 1.6 times over 

that of service members who were not deployed and did 

not have combat experience.29

Those deployed service members who are blast-exposed 

from the detonation of IEDs in OIF and OEF have also 

been shown to be at a significantly higher increased 

risk of acquiring a hearing loss.29 Additionally, hearing loss and tinnitus are thought to be overlooked and 

underreported when such injuries occur in conjunction 

with life-threatening injuries in polytraumatic events. 

Although blast exposures typically inflict head injuries, 

much is unknown regarding the prevalence of blastrelated ear trauma (ie, hearing loss or central auditory 

processing difficulties).10,11 However, blast-related auditory injuries among US military personnel during deployment account for as many as 78% of injuries. Detonation of explosives such as IEDs, RPGs, and VBIEDs 

not only expose military personnel to a blast overpressure wave, the individual may also subsequently be exposed to hazardous noise levels, ototoxic agents within 

the blast wave, combined effects of inhaled toxins with 

hazardous noise levels, and ototoxic medications used 

to treat sustained illness or injuries within the deployed 

environment.28,30 Recovery from hearing loss to preblast 

exposure levels may take hours to week(s), which can 

compromise situational awareness and operational readiness.7,31 Soldiers have reported an immediate decrease 

in hearing sensitivity and/or a new awareness of tinnitus 

post-blast exposure.7,16,31,32

Combat-related blast exposure may be unpredictable 

in onset and length. A service member who cannot anticipate a blast and is not using an issued HPD is unprepared and/or unprotected against the blast overpressure 

wave and hazardous noise levels to the auditory system, 

increasing the likelihood of acquiring an acoustic injury. 

A previous study found that blast exposure of deployed 

Soldiers who were were not using an HPD resulted in a 

significant and mixed hearing loss (ie, conductive and 

sensorineural).32 However, use of an HPD at the time of 

blast-exposure does not prevent damage to the ear, as 

there is reported evidence of TM perforation with use 

of an HPD.33

Tinnitus is a known symptom associated with mTBI, 

both with and without loss of consciousness. A head injury with resulting mTBI increases the patients’ likelihood of reporting tinnitus by 1.70 times compared to 

other non-head injuries.34 Oleksiak et al found a self-reporting rate of 59.5% for difficulty hearing and 75.7% for 

tinnitus among sampled Veterans diagnosed with mTBI 

during 2007-2009.8

 Dougherty et al reported that military personnel were 4 times more likely to report tinnitus in the presence of a TM rupture and 17% more likely 

in the presence of a concomitant head injury.31 Lew et al 

reported a 38% prevalence of tinnitus in patients with 

blast-exposed TBI.15 Additionally, use of an HPD was 

found to reduce by 43% the likelihood of a middle or inner ear injury involving tinnitus diagnoses.31

Epidemiologic studies are beneficial in audiology because they:

` Establish causation for hearing loss and tinnitus acquired during deployment.

` Identify risk factors that may further decrease hearing sensitivity or factors that increase risk to developing tinnitus.

` Identify environmental factors that may increase 

the likelihood of acquiring a hearing loss or tinnitus.

While epidemiologic studies of hearing loss and/or tinnitus acquired from military service within the active 

duty and veteran populations during these recent operational conflicts are limited, Theodoroff et al provided 

a comprehensive review of hearing loss prevalence and 

risk factors associated with US service members and 

Veterans who served in OIF, OEF, and/or OND.10

McIlwain et al reported the effects of blast exposure and 

HPD use and subsequent acoustic trauma in deployed 

US Army Soldiers serving in OIF.32 A significant difference in audiometric thresholds at 500 Hz, 1000 Hz, and 

2000 Hz between those blast-exposed using HPD and 

nonblast was found. Additionally, a significant difference was noted at audiometric octave frequencies 500 

Hz to 12,000 Hz between those blast-exposed who did 

not wear HPDs and an unexposed control group. The 

Millennium Cohort Study on hearing loss, one of the 

larger prospective studies providing audiometric data 

from US military personnel, reported that personnel 

with combat-related head injury were 7 times more 

likely to have new-onset hearing loss than personnel 
54 http://www.cs.amedd.army.mil/amedd_journal.aspx

without such head injury.29 Additional risk factors that 

increase a service member’s likelihood of acquiring an 

ear injury include gender (male), age (greater than 40 

years), and rank (officer).35

The known association between deployment-related 

mTBI and MOI with changes in hearing sensitivity 

(ie, audiometric thresholds) and/or tinnitus in active 

duty or reservist service members is limited in scope. 

Previous studies have analyzed: hearing sensitivity in 

combat Veteran populations after separation from service 5,8,14,15,17,36,37; specified MOI, with no discussion of 

TBI 15,36,37; TBI without identifying the degree of severity30; and mTBI with unspecified MOI.8,17 The purpose 

of this retrospective cohort study was to explore risk factors associated with tinnitus and hearing loss in a cohort 

of service members who were diagnosed with deployment-related mTBI. This cohort was divided into exposure groups (blast and nonblast) to compare the risk factors for hearing loss and tinnitus between the 2 groups.

Methods

Study Population

This study was an addendum to a study completed at 

Landstuhl Regional Medical Center (LRMC) of patients 

with mTBI who received care by the TBI Recovery interdisciplinary team (ie, neurology, optometry, ophthalmology, audiology, physical therapy, occupational therapy, and behavioral health).38 The study was approved by 

the Brooke Army Medical Center Institutional Review 

Board and US Army Medical Research and Materiel 

Command Office of Human Research Protection.

The current study was designed as a longitudinal audiologic retrospective electronic health record chart review 

of 500 military personnel diagnosed with deploymentrelated mTBI. Records were stratified by MOI, with 456 

of 500 meeting inclusion criteria as illustrated in the 

Figure. Criteria for inclusion were US military personnel who:

1. Sustained a head injury resulting in the diagnosis 

of deployment-related mTBI by a neurologist within 

the TBI Recovery Team at LRMC;

2. Were treated between January 2008 and February 

2011;

3. Had at least one audiometric test record within the 

military electronic health record (AHLTA) and/or 

Defense Occupational and Environmental Health 

Readiness System Data Repository (DOEHRS-DR) 

(9 personnel were excluded for not having either a 

DoD Form 2215 (DD 215), a DD 2216, or clinical 

audiogram); and

4. Recorded MOI of either blast-exposed or nonblast 

(35 people were excluded for sustaining a combination injury, ie, blast-exposed plus nonblast head 

injury).

Participants were either medically evacuated from theater or stationed in the vicinity of LRMC and referred 

Study cohort distribution of mechanism of injury. 

mTBI indicates mild traumatic brain injury;

LRMC, Landstuhl Regional Medical Center.

Blunt

Force

n(NB)=51

Rollover

n(NB)=8

Bullet,

Fragment,

Other

n(NB)=6

Sports,

Recreation

n(NB)=5

CoupContrecoup

n(NB)=4

Motor

Vehicle

Accident

n(NB)=32

Fall

n(NB)=45

No

Answer

Given

n(NB)=2

Nonblast Injury 

(NB)

n=153

Improvised

Explosive

Device

n(BE)=250

Rocket

Propelled

Grenade

n(BE)=31

Mortar

n(BE)=15

Grenade

n(BE)=3

Other

n(BE)=1

No

Answer

Given

n(BE)=3

Blast-Exposed

Injury (BE)

n=303

mTBI Diagnosis

And

Seen at LRMC Eye Clinic

N=500

No Audiometric

Information

n=9

Combination

Injury

n=35

Hearing Loss and Tinnitus in Military Personnel

with Deployment-Related Mild Traumatic Brain Injury
October – December 2016 55

The Army Medical Department Journal

by their primary care provider to the TBI Clinic. The diagnosis of mTBI was based on DoD criteria: loss of consciousness of no more than 30 minutes, posttraumatic 

amnesia of no more than 24 hours, alteration in mental 

state, a Glasgow Coma Scale score from 13 to 15, and 

normal structural brain imaging.9

Measures

The study analyzed audiometric threshold information 

occurring at 5 common points in time during which the 

deployed service member encountered a DoD audiologist and/or Army Occupational Hearing Conservation 

Technician. In chronological order, audiograms that 

were collected and analyzed include: 

1. Reference audiogram upon entry to service (ie, DD 

2215 or DD 2216 (line 15c));

2. Predeployment DD 2216;

3. LRMC clinical audiogram completed 0-90 days 

postinjury;

4. Postdeployment DD 2216 or LRMC Clinical audiogram completed 90 days or more following injury, 

whichever was first; and 

5. The last DD 2216 on record.

Clinical audiograms completed at the Audiology Clinic 

at LRMC were obtained from AHLTA, and hearing 

readiness audiograms (ie, DD 2215 and DD 2216) were 

obtained from the DOEHRS-DR.

Hearing loss was quantified by identifying and calculating STS for each participant record between the test 

of interest (ie, predeployment, LRMC, postdeployment, 

last on record) and the reference audiogram. The STS 

was defined according to the 1998 version (now superseded) of the Department of Army Pamphlet 40-501, as 

that was the edition governing the Army Hearing Program at the time of service delivery. A STS in hearing 

is defined as a change in at least one ear noted between 

the test of interest and reference audiogram as either an 

average at 2000 Hz, 3000 Hz, and 4000 Hz of ±10dBHL 

or more, or ±15 dBHL or more at 1000 Hz, 2000 Hz, 

3000 Hz, or 4000 Hz.39

Tinnitus was quantified by querying the participants’ 

AHLTA/DOEHRS-DR record for a previous diagnosis 

or record of tinnitus in at least one ear. Demographic 

and clinical characteristics were also queried from 

DOEHRS-DR for analyses. Demographic information 

included gender, duty status, branch of service, rank, 

military occupational specialty (MOS), age, and race/

ethnicity. Clinical characteristics that were obtained include diagnoses of PTSD, sleep problems, hyperacusis/

noise sensitivity, total number of previous TBIs, and 

prescription or over-the-counter medication use. Details 

of injury characteristics were also captured, including 

mounted/dismounted status, conflict in which the service member was injured (OIF or OEF), and total number of previous deployments.

Statistical Analysis

In addition to audiometric information, demographic 

and clinical history data reported in the LRMC medical record for each patient were collected, coded, and 

entered into an Excel spreadsheet. Prescription and 

over-the-counter medications used by each patient and 

reported in the medical record were also captured in 

the spreadsheet, which was imported into SPSS version 

21 (IBM Corp, Armonk, NY) for descriptive analysis 

of the demographic variables, and also into SAS version 9.1.3 (SAS Institute Inc, Cary, NC) for bivariate 

and multivariate analysis of each demographic or clinical variable with respect to blast exposure status, STS, 

or tinnitus. A χ2 test was performed to determine the 

statistical significance of association between each categorical demographic or clinical variable and blast exposure status. The relative risk (RR) with 95% confidence 

interval (CI) of developing an STS or tinnitus was calculated for each demographic or clinical characteristic. An 

independent samples t test was performed to determine 

if the difference in mean age between the blast-exposed 

and nonblast groups was statistically significant.

The date on which each audiogram was completed is recorded on DD 2215 and DD 2216. Consistent with the 

retrospective cohort study design used in the current 

study,40 these dates were used to calculate person-time 

during which patients were at risk of developing an STS. 

The amount of person-time contributed by each patient 

to the study was calculated by subtracting the date of the 

reference audiogram from the date of the audiogram on 

which an STS was first identified (or the date of the last 

audiogram on file if the patient did not develop an STS). 

For each patient, the number of elapsed days between 

the 2 dates was divided by 365.25 and summed across 

all patients to obtain the total person-years at risk, which 

serves as a denominator for calculating incidence rates of 

STS. The number of STS cases in each subgroup (blastexposed and nonblast) was divided by the total personyears in each group and multiplied by 1,000 to calculate 

the incidence rate of STS per 1,000 person-years for each 

group. The rate for the blast-exposed group was divided 

by the rate for the nonblast group to calculate a rate ratio 

comparing the incidence rates between the 2 groups.

Finally, to adjust for multiple demographic and clinical 

variables simultaneously, 2 multiple logistic regression 

models were constructed for multivariate analysis, one 
56 http://www.cs.amedd.army.mil/amedd_journal.aspx

with STS as the dependent variable and the other with 

tinnitus as the dependent variable, using forward selection of variables with the significance level for entry into the models set at 0.05. Age was divided into 4 

groups (quartiles) to enable categorical analysis, with 

patients aged 18 to 22 years (youngest quartile) serving 

as the reference group. The adjusted odds ratio (OR) 

(95% CI) of developing STS or tinnitus was calculated 

for each statistically significant covariate entered into 

the logistic regression models.

Results

Demographic and Clinical Characteristics

Table 1 shows the demographic characteristics of 

patients by blast exposure status. On average, blastexposed patients were younger (mean age 27.8 years) 

compared to nonblast patients (mean age 30.6 years), 

with greater percentages of males, Marine Corps service, and enlisted personnel. Compared to nonblast 

patients, greater percentages of blast-exposed patients 

served in the infantry, were dismounted at the time of 

injury, and had been deployed two or more times. No 

statistically significant differences in race, duty status, 

and conflict at the time of injury were found between 

blast-exposed and nonblast patients.

Table 2 shows the clinical characteristics of patients 

by blast exposure status. Compared to nonblast patients, greater percentages of blast-exposed patients 

reported a previous TBI, a history of unprotected 

noise exposure, tinnitus, and hyperacusis/noise sensitivity. A greater percentage of blast-exposed patients 

than nonblast patients reported routinely using the tactical communications system (TCS) as an HPD, while 

a greater percentage of nonblast patients than blastexposed patients reported routinely using no HPD at 

all. A greater percentage of blast-exposed patients had 

developed an STS between their reference and subsequent audiograms than nonblast patients, but this difference was just shy of being statistically significant 

(P=.06) at the alpha level of 0.05. No statistically significant differences in nicotine use, PTSD diagnosis, 

sleep problems, and final disposition were found between blast-exposed and nonblast patients.

Auditory Injury Outcomes

Of 456 patients in this study, 291 (64%) had developed 

an STS. Among the 304 blast-exposed patients, 203 

(67%) had developed an STS, and among the 152 nonblast patients, 88 (58%) had developed an STS. Because 

not all patients had undergone an audiometric examination at each encounter captured in this study, the number of patients examined at each encounter is fewer than 

the cohort total of 456. Among the 432 patients with a 

predeployment audiogram, 115 (25% of the 456 cohort 

total) had already developed an STS compared to their 

reference audiograms.

Table 3 shows the incidence rates of STS per 1,000 person-years by blast exposure status, post-mTBI only, and 

age at time of mTBI. Blast-exposed patients developed 

Table 1. Patient Demographic Characteristics by Blast Exposure 

Status.

Characteristic Total

(%N)

N=456

Blast

(%n)

n=304

Nonblast

(%n)

n=152

P

value

Age, year (mean±SD) 28.8±8.1 27.8±7.6 30.6±8.7 .001

Sex <.001

Male 416 (91%) 298 (98%) 118 (78%)

Female 40 (9%) 6 (2%) 34 (22%)

Race .14

White 312 (68%) 208 (68%) 104 (68%)

Black 71 (16%) 42 (14%) 29 (19%)

Hispanic 52 (11%) 41 (13%) 11 (7%)

Other 21 (5%) 13 (4%) 8 (5%)

Service <.001

Army 378 (83%) 254 (84%) 124 (82%)

Marine Corps 44 (10%) 38 (12%) 6 (4%)

Air Force 23 (5%) 7 (2%) 16 (10%)

Navy 10 (2%) 5 (2%) 5 (3%)

Civilian 1 (<1%) 0 (0%) 1 (1%)

Duty Status .12

Active duty 404 (89%) 274 (90%) 130 (86%)

Reserve 18 (4%) 8 (3%) 10 (6%)

National Guard 32 (7%) 21 (7%) 11 (7%)

Other/Civilian* 2 (<1%) 1 (<1%) 1 (1%)

Military Rank .01

E1-E6 377 (83%) 259 (85%) 118 (78%)

E7-E9 42 (9%) 29 (10%) 13 (8%)

Officer/Warrant Officer 36 (8%) 16 (5%) 20 (13%)

Civilian* 1 (<1%) 0 (0%) 1 (1%)

Military Occupational Specialty <.001

Infantry 173 (38%) 142 (47%) 31 (20%)

Other/NR 283 (62%) 162 (53%) 121 (80%)

Mounted Status .001

Mounted 205 (45%) 121 (40%) 84 (55%)

Dismounted 242 (53%) 178 (58%) 64 (42%)

Other/NR* 9 (2%) 5 (2%) 4 (3%)

Conflict at Time of Injury .19

OIF 273 (60%) 179 (59%) 94 (62%)

OEF 172 (38%) 123 (40%) 49 (32%)

Other/Not Deployed* 11 (2%) 2 (1%) 9 (6%)

No. of Deployments .01

0 16 (4%) 9 (3%) 7 (5%)

1 139 (30%) 88 (29%) 51 (33%)

2 170 (37%) 105 (34%) 65 (43%)

3+ 131 (29%) 102 (34%) 29 (19%)

NR indicates not recorded.

*Not included in χ2 analysis.

Hearing Loss and Tinnitus in Military Personnel

with Deployment-Related Mild Traumatic Brain Injury
October – December 2016 57

The Army Medical Department Journal

an STS at a higher rate (115.5 cases per 1,000 personyears) than nonblast patients (92.8 cases per 1,000 person-years), in a blast-to-nonblast rate ratio of 1.24. After 

excluding the 115 patients who had already developed 

an STS on their predeployment audiograms compared 

to their reference audiograms, leaving the reference 

and postinjury (LRMC, postdeployment, and last) audiograms of the remaining 341 patients in the analysis, 

blast-exposed patients still developed an STS post-injury 

at a higher rate (94.0 cases per 1,000 person-years) than 

nonblast patients (75.8 cases per 1,000 person-years), in 

a blast-to-nonblast rate ratio of 1.24. When stratifying 

by age at the time of mTBI, blast patients aged 18 to 22 

years developed an STS at the highest rate (238.7 cases 

per 1,000 person-years).

Analysis of the associations between STS or tinnitus and 

selected patient characteristics showed that only infantry (crude RR=1.21, 95% CI 1.06-1.39) and unprotected noise exposure (crude RR=1.27, 95% CI 1.11-1.46) 

were significantly associated with STS in the bivariate 

analysis. When adjusting for covariates using multiple 

logistic regression, these 2 variables entered the logistic 

regression model as statistically significant covariates 

associated with STS. Patients who served in the infantry 

were 54% more likely to develop an STS than patients 

who did not (adjusted OR=1.54, 95% CI 1.00-2.38), and 

patients who reported a history of unprotected noise exposure were 75% more likely to develop an STS than patients who did not (adjusted OR=1.75, 95% CI 1.12-2.75).

Blast-exposure status, Marine Corps service, an infantry MOS, PTSD diagnosis, unprotected noise exposure, 

TCS use, hyperacusis/noise sensitivity, and zolpidem (eg, 

Edluar, Zolpimist, Intermezzo, Ambien) use were each 

significantly associated with tinnitus in the bivariate 

analysis. On the other hand, patients aged 34 to 59 years 

and black patients were significantly less likely to develop tinnitus when compared to their respective reference 

groups (patients aged 18 to 22 and white patients, respectively). However, when adjusting for covariates using 

multiple logistic regression, only Marine Corps service, 

PTSD diagnosis, unprotected noise exposure, and zolpidem use entered the logistic regression model as statistically significant covariates associated with tinnitus. 

Patients who served in the Marine Corps were 7 times 

more likely to develop tinnitus than the reference group 

of patients who served in the Army (adjusted OR=7.05, 

95% CI 2.65-18.76). Patients who reported a PTSD diagnosis were 66% more likely to develop tinnitus than patients who did not (adjusted OR=1.66, 95% CI 1.05-2.61). 

Patients who reported a history of unprotected noise exposure were 2.5 times more likely to develop tinnitus 

than patients who did not (adjusted OR=2.51, 95% CI 

1.62-3.91), and those who reported zolpidem use were 

twice as likely to develop tinnitus than patients who did 

not (adjusted OR=1.97, 95% CI 1.12-3.48).

Table 2. Patient Clinical Characteristics by Blast Exposure 

Status.

Characteristic Total

(%N)

N=456

Blast

(%n)

n=304

Nonblast

(%n)

n=152

P

value

Previous Traumatic Brain Injury .04

Yes 153 (34%) 112 (37%) 41 (27%)

No 303 (66%) 192 (63%) 111 (73%)

History of Unprotected Noise Exposure <.001

Yes 159 (35%) 137 (45%) 22 (14%)

No 258 (57%) 137 (45%) 121 (80%)

NR* 39 (8%) 30 (10%) 9 (6%)

Hearing Protection Device Issued <.001

TCS 183 (40%) 162 (53%) 21 (14%)

Earplugs 15 (3%) 13 (4%) 2 (1%)

Headset 12 (3%) 8 (3%) 4 (3%)

Other 4 (1%) 1 (<1%) 3 (2%)

None 82 (18%) 18 (6%) 64 (42%)

NR* 160 (35%) 102 (34%) 58 (38%)

Significant Threshold Shift .06

Yes 291 (64%) 203 (67%) 88 (58%)

No 165 (36%) 101 (33%) 64 (42%)

Tinnitus <.001

Yes 242 (53%) 181 (59%) 61 (40%)

No 190 (42%) 106 (35%) 84 (55%)

NR* 24 (5%) 17 (6%) 7 (5%)

Hyperacusis/Noise Sensitivity <.001

Yes 82 (18%) 69 (23%) 13 (8%)

No 362 (79%) 227 (75%) 135 (89%)

NR* 12 (3%) 8 (2%) 4 (3%)

Nicotine Use .47

Yes 189 (41%) 129 (42%) 60 (39%)

No 257 (56%) 167 (55%) 90 (59%)

NR* 10 (2%) 8 (3%) 2 (1%)

Posttraumatic Stress Disorder .46

Yes 323 (71%) 218 (72%) 105 (69%)

No 130 (28%) 83 (27%) 47 (31%)

NR* 3 (1%) 3 (1%) 0 (0%)

Sleep Problems .78

Yes 384 (84%) 255 (84%) 129 (85%)

No 66 (14%) 45 (15%) 21 (14%)

NR* 6 (1%) 4 (1%) 2 (1%)

Final Disposition .84

Separation 232 (51%) 153 (50%) 79 (52%)

Return to Duty 95 (21%) 61 (20%) 34 (22%)

Rehabilitation 81 (18%) 56 (18%) 25 (16%)

Retired 41 (9%) 29 (10%) 12 (8%)

Other/NR* 7 (1%) 5 (2%) 2 (1%)

NR indicates not recorded.

TCS indicates tactical communications system

*Not included in χ2 analysis.
58 http://www.cs.amedd.army.mil/amedd_journal.aspx

Comment

This study was designed to characterize the incidence of 

hearing loss and tinnitus with respect to blast exposure 

in a cohort of US military personnel diagnosed with deployment-related mTBI. Differences in the demographic 

and clinical characteristics of personnel who were at 

greater risk of developing either auditory injury outcome (ie, STS or tinnitus) were found. Our findings indicate that in this cohort, blast exposure was significantly 

associated with younger age, males, Marine Corps service, junior enlisted rank, infantry, dismounted status 

at the time of injury, and greater numbers of deployments. Blast exposure was also significantly associated 

with previous TBI, unprotected noise exposure, tinnitus, 

and hyperacusis/noise sensitivity. However, our findings indicate that blast exposure was not significantly 

associated with hearing loss (although the association 

of P=.06 was just short of being statistically significant 

at the alpha level of 0.05), but unprotected noise exposure was associated with hearing loss. Blast exposure 

was significantly associated with tinnitus, but not when 

adjusted for other demographic and clinical covariates, 

whereas unprotected noise exposure was associated 

with tinnitus.

Auditory Injury Outcome: STS

This study found an elevated incidence of hearing loss 

among blast-exposed mTBI patients compared to nonblast mTBI patients, consistent with the previous studies.14,30 Over the surveyed career span (person-time at 

risk for developing hearing loss) blast-exposed mTBI 

patients developed hearing loss at a 24% higher rate 

than nonblast mTBI patients. This differential incidence 

was highest among patients aged 18 to 22 years, the 

youngest quartile of patients in this study. Blast-exposed 

patients in this age group developed hearing loss at a 

41% higher rate than nonblast patients in this age group. 

Similarly, Dougherty et al reported blast-exposed service members who received a head injury were 32% 

(adjusted OR=1.32, 95% CI, 1.06-1.65) more likely to 

develop a hearing loss than service members without a 

head injury.31 The difference in increased risk ratios between the current study and the Dougherty et al study 

may stem from different population samples and sizes. 

The Dougherty et al study did not include nonblast head 

injuries, and mTBI information was not captured. Additionally, the sampled population (n=4,817) was that of 

US service members who served in OIF and were both 

blast-exposed and received ear injuries.31

Results from the current study identified a STS in 25% 

of the total population at the surveyed predeployment 

audiogram or the last audiogram measured prior to injury. This may be due in part to the fact that a reported 

66% of the total cohort reported being deployed 2 or 

more times prior to the current mTBI diagnosis. Previous reports have indicated that both deployment and 

combat experience increase a service member’s likelihood of hearing loss.28,29 It is likely possible that over 

half of the surveyed cohort may have had an STS (ie, 

hearing loss) that could be tied to military service and/or 

deployment prior to the current mTBI diagnosis. Rather 

than labeling a hearing loss by degree (mild, moderate, 

etc) alone, identifying an STS will capture those individuals whose hearing is functionally “within normal 

limits,” and measureable damage to the auditory system 

is evidenced by a significant decrease in hearing sensitivity. Audiologic tests such as otoacoustic emissions 

and acoustic reflex thresholds have been shown to be 

abnormal in the presence of normal hearing in mTBI 

patients.4,41 Therefore, these tests should be considered 

for inclusion in the audiologic test battery of patients 

presenting with mTBI.

Blast injuries can result in acoustic trauma either in isolation or in the presence of a head injury. Head injuries 

have previously been shown to be a risk factor for hearing loss. Lew et al reported an average 10 dBHL difference between blast-exposed and nonblast TBIs, with 

the more significant hearing loss occurring within the 

blast-exposed TBI group.15 The 

current study defined hearing loss 

as an identified STS rather than a 

measured audiometric threshold 

(ie, dBHL level) among a population of service members with diagnosed mTBI. Results indicate, 

although not statistically significant, that mTBI caused by blast 

exposure increased the likelihood 

of a service member developing 

an STS by 15% (RR=1.15, 95% CI 

0.99-1.35). Acoustic trauma, and 

subsequent hearing loss, which 

Table 3. Incidence rates of STS per 1,000 person years by blast exposure status, postmTBI only, and age at time of mTBI.

Diagnosed 

STS

Blast (B) Nonblast (NB) Rate

ratio

(B/NB)

n Total

person-years

at risk

Rate per

1,000

person-years

n Total

person-years

at risk

Rate per 

1,000

person-years

All (N=291) 203 1,757.5 115.5 88 948.1 92.8 1.24

Post-mTBI

Only

126 1,340.5 94.0 50 659.5 75.8 1.24

Age (years)

18-22 64 268.1 238.7 12 70.8 169.4 1.41

23-26 51 291.2 175.2 21 119.2 176.2 0.99

27-33 49 488.5 100.3 26 300.0 86.7 1.16

34-59 39 695.6 56.1 29 458.1 63.3 0.89

Hearing Loss and Tinnitus in Military Personnel

with Deployment-Related Mild Traumatic Brain Injury
October – December 2016 59

The Army Medical Department Journal

can result from blast exposure to events such as IEDs 

or VBIEDs, have been found to cause permanent and 

large threshold shifts above 8000 Hz.32 The DOEHRS 

audiometric testing typically does not exceed 6000 Hz, 

however 8000 Hz is an optional test frequency. This is 

an observed limitation of the current study as our analysis does not exceed 6000 Hz.

One such study which reviewed noise-induced hearing 

injuries (NIHI) by diagnosis codes during OIF in active 

duty US service members 35 noted both age and gender 

effects within the study cohort. Men had 15% to 78% 

greater rates of diagnoses than women. The risk ratio 

analysis in this study revealed, although not statistically 

significant, a gender effect with men at a greater risk for 

both STS and tinnitus. However, generalization is limited, as gender groups are not equal with 91% of the total 

sample population identified as male. Bivariate analyses 

of gender differences between MOI groups indicate a 

statistically significant difference between those blastexposed and nonblast head injuries. Similarly, infantry 

or combat arms MOSs were reported to have higher 

rates of NIHI than other MOSs. This supports our finding that an infantry MOS increases one’s likelihood of 

developing an STS by 54% (adjusted OR=1.54, 95% CI 

1.00-2.38) compared to all other surveyed MOSs, which 

is statistically significant at the alpha level of 0.05.

Auditory Injury Outcome: Tinnitus and Hyperacusis

The current study found a prevalence of approximately 

53% of reported tinnitus in at least one ear in mTBI patients, with a prevalence of 59% of the blast-exposed 

cohort and 40% of those patients with a nonblast mTBI. 

The overall prevalence of tinnitus in the current study 

differs from the prevalence rate of 75% reported by 

Oleksiak et al.8

 This discrepancy may be due to either a 

smaller sample size compared to our study (37 of 75 Veterans who completed an audiologic assessment) and/or 

the referral criteria (Veterans who had both mTBI and 

newly identified hearing loss).

Results of the current study indicate that blast exposure 

increased the likelihood of self-reporting of and a diagnosis of tinnitus in at least one ear by 50% compared 

to those service members who were diagnosed with a 

nonblast mTBI (crude RR=1.50, 95% CI 1.21-1.85). This 

was statistically significant at the alpha 0.05 level. Shah 

et al found blast-exposed patients with TBI are 2.5 times 

more likely to have tinnitus postinjury than those patients who have nonblast TBIs.14 Similarly, those service 

members diagnosed with deployment-related TBI were 

found to be 2.7 times more likely to report tinnitus after 

deployment than those without a TBI.42

Results from the current study indicate a number of factors that would indicate a protective effect against tinnitus. One such factor is age. The current study found service members aged 34 to 59 years were 22% less likely 

to have tinnitus than the 18 to 22 year old service members (crude RR=0.78, 95% CI 0.61-1.00), P=.05. Helfer 

et al reported that service members over the age of 40 

years were 3 to 5 times more likely to seek audiologic 

evaluation and receive a NIHI diagnosis than those aged 

17 to 19 years during the surveyed time period, with 

29.1% of the sampled population receiving a diagnoses 

of tinnitus (unspecified or subjective).35 This might coincide with a number of factors including evaluations prior 

to separation from service, delayed onset of hearing loss, 

and NIHI covering diagnoses other than hearing loss 

(tinnitus, TM perforation, etc).

Yet another factor that revealed a reduced risk for developing tinnitus was race/ethnicity. The current study 

found that among service members who report their race/

ethnicity as white, black, or Hispanic, only those service members who identified as black were at a reduced 

risk of developing tinnitus by 31% (crude RR=0.69, 

95% CI 0.51-0.95), P=.05. Similarly, Shargorodsky et 

al reported participants who report their race/ethnicity 

as black, non-Hispanic, and Hispanic had lower risk of 

any tinnitus than white, non-Hispanic participants by 

38% (OR=0.62, 95% CI, 0.55-0.69) and 30% (OR=0.70, 

95% CI, 0.61-0.80), respectively. Further, participants 

who report their race/ethnicity as black, non-Hispanic, 

and Hispanic were found to be at lower risk for frequent 

tinnitus than white, non-Hispanic participants by 59% 

(OR=0.41, 95% CI, 0.31-0.54) and 38% (OR=0.62, 95% 

CI, 0.50-0.77), respectively.43

Hyperacusis, or sensitivity to certain sounds and loudness levels, can occur as a result of blast-exposure. Examination of auditory injuries following blast exposure 

within civilian studies reveal an incidence rate for hyperacusis or sound distortion of 30% immediately following exposure.44 Additionally, PTSD can exacerbate 

sound-tolerance issues, as one study found significant 

differences in sound-tolerance discomfort in Veterans 

diagnosed with PTSD and tinnitus compared to Veterans with tinnitus only.45 The current study revealed 

18% (n=82) of the total population having been either 

diagnosed with hyperacusis or noise sensitivity. However, when the rates were stratified by MOI, it was revealed that 23% of patients who were blast-exposed 

were diagnosed with either hyperacusis or noise sensitivity compared to 8% of patients who were not exposed. 

Bivariate analysis revealed a statistically significant increase of risk of tinnitus of 34% (crude RR=1.34, 95% 
60 http://www.cs.amedd.army.mil/amedd_journal.aspx

CI=1.13-1.59) among patients who self-report hyperacusis or noise sensitivity.

Unprotected Noise Exposure/HPD Use

Bivariate analysis of HPD used with respect to hearing loss and tinnitus appeared to show an elevated risk 

(rather than a protective effect) of developing either auditory injury outcome when using the TCS. This may 

not accurately reflect the effectiveness of the TCS as an 

HPD, but may instead be an artifact of self-reporting 

by the patients in this study. “Type of Personal Hearing Protection Used” recorded on DD 2216 (line 15g) is 

inadequate to evaluate as a risk factor with respect to 

hearing loss and tinnitus, since it records “type of hearing protection that is routinely used by individual,” not 

whether the individual was wearing hearing protection 

at the time of injury/acoustic trauma. Self-reported history of unprotected noise exposure may be a more accurate proxy for estimating routine compliance with hearing protection (or the lack thereof), since it appears to be 

a consistently robust risk factor predicting the elevated 

risk of both hearing loss and tinnitus in both the crude 

and adjusted risk analyses in this study. Similarly, Wells 

et al reported an increased odds of 18% for developing 

a hearing loss in service members whose MOS required 

the use of an HPD.29

Individuals engaged in combat and military operations 

rely on communication and hearing abilities to facilitate 

both teamwork and mission success. Hearing protective 

devices can often be a barrier to these efforts which may 

influence the actual use of the HPD by the service member. Previous studies have reported the difficulty experienced wearing and using HPDs during combat operations.29,46 This may be due to a perceived diminished 

ability to: communicate with fellow team members; 

detect, perceive, and understand auditory messages, 

warnings, and/or commands; detect enemy threats; use 

and operate radio or intercom units; supervise ground 

troops not using radio communications; and/or maintain 

situational awareness including sound localization.47-49

Other Factors

Auditory damage and subsequent hearing loss can be 

due to military activity such as noise exposure, blast exposure injuries, and ototoxic medications, either in isolation or combination, resulting in a synergistic effect.30

This study attempted to analyze the use of prescription 

and over-the-counter medications by study subjects to 

determine if such use was associated with hearing loss 

and/or tinnitus, especially those that are known to be 

ototoxic. Of the 71 medications documented in LRMC 

medical records as being used by patients in this study, 

only the use of zolpidem, a prescription sleep aid, was 

associated with a two-fold increased risk of tinnitus. 

Most of these medications were used by too few patients 

in this study to have sufficient statistical power to show 

any differences in hearing loss and/or tinnitus between 

users and nonusers. Greater numbers of patients using 

a given medication under study are therefore needed to 

determine its ototoxicity in future pharmacoepidemiologic studies.

Previous studies have reported that mTBI is typically 

associated with higher rates of PTSD.34,50 This study 

found 71% of the total population cohort (323 of 456 

patients), or 72% of the blast-exposed and 69% of the 

nonblast patient groups, with a concurrent diagnosis of 

PTSD. Multivariate analysis revealed that the risk of developing tinnitus increased by 66% (adjusted OR=1.66, 

95% CI 1.05-2.61) among mTBI patients with documented PTSD. Similarly, MacGregor, Dougherty, Tang, and 

Galarneau report statistically significant associations 

between tinnitus and mTBI (OR=1.63, 95% CI 1.10-

2.41) after adjusted for PTSD, depression, age, combat 

blast mechanism, combat exposure, and Injury Severity 

Score.34 Additionally, both PTSD and depression are associated comorbid diagnoses with mTBI, affecting up 

to 40% of cases.51 While no identifiable association between the 2 diagnoses has been reported,42 there is overwhelmingly more evidence in support of an association 

between PTSD and tinnitus than not.45

The current study found, although not statistically significant, that nicotine use increased the relative risk of 

acquiring an STS by 4% (crude RR=1.04, 95% CI 0.91-

1.20), compared to nonsmokers. The identified association in the current study is consistent with literature in 

identifying a positive relationship between use of nicotine and hearing loss, with reports of current smokers 

being at an increased risk of 1.2 to 1.7 times.29,52,53 A 

previous study reports current smokers were 54% more 

likely (age-adjusted OR=1.54, 95% CI 1.31-1.81) while 

former smokers were 30% more likely (age-adjusted 

OR=1.30, 95% CI 1.16-1.46) to report any tinnitus compared to those who never smoked.43 This supports our 

finding, which, although not significant, reveals those 

service members who were diagnosed with mTBI and 

reported nicotine use were 17% (crude RR=1.17, 95% 

CI 0.99-1.39) more likely to also report and be diagnosed with tinnitus in at least one ear.

We recognize that our study is limited by a number of 

factors. The DOEHRS system does not regularly test 

above 6000 Hz in either ear. Therefore, this information 

is not available within our cohort. A future study should 

be executed with focus on the effect of TBI and MOI 

on hearing thresholds within the high and ultra-high 

Hearing Loss and Tinnitus in Military Personnel

with Deployment-Related Mild Traumatic Brain Injury
October – December 2016 61

The Army Medical Department Journal

frequency range (ie, above 6000 Hz). Additionally, we 

are limited by the data set. Not all patient files had recorded audiograms at each of the five surveyed points 

in time.

Conclusions

Interest in hearing loss and tinnitus within this population is driven by and becomes even more significant 

when combined with the fact that tinnitus and hearing loss are respectively the number 1 and 2 serviceconnected disabilities across the US armed forces. A 

number of factors would suggest that the total number 

of service members and combat Veterans with serviceconnected hearing loss and/or tinnitus is only to increase over time. Unlike other common military- and/

or combat-related injuries, hearing loss is likely to 

progress with age.30 Additionally, both acoustic trauma 

and/or blast exposure have been tied to delayed-onset 

hearing loss. The current clinical recommendation is 

that those exposed should receive long-term audiologic 

monitoring.3,14,32 The findings from this study revealed 

no statistically significant difference in likelihood of developing a STS between MOI groups. This may suggest 

that experienced communication difficulties may lie in 

higher ordered structures beyond the peripheral auditory system and may not be captured with a standard 

audiometric threshold examination.

Acknowledgments

This research was funded by the Military Operational 

Medicine Research Program of the US Army Medical 

Research and Materiel Command. This research was 

also supported in part by the Postgraduate Research Participation Program and an appointment to the Faculty 

Participation Program at the US Army Aeromedical Research Laboratory administered by the Oak Ridge Institute for Science and Education through an interagency 

agreement between the US Department of Energy and 

the US Army Medical Research and Materiel Command.

We thank Mr Trevor Jerome for his assistance with 

MATLAB coding and Dr Jordan Jones for her assistance 

in stratifying data for further analysis.

This study was approved by the Brooke Army Medical 

Center Institutional Review Board and US Army Medical Research and Materiel Command Office of Research 

Protection, and each participant signed informed consent.

We do not plan to inform participants of the publication 

of this study.

Portions of this work were presented at the Military 

Health Systems Research Symposium, Fort Lauderdale, 

FL, August 2014, and the Joint Defense and Veterans Audiology Conference, Orlando, FL, March 2015.

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at: http://www.vba.va.gov/reports/abr/index.asp. 

Accessed July 29, 2015.

25. Department of Veteran Affairs. Annual Benefits 

Report: Fiscal Year 2013 [internet]. Available 

at: http://www.vba.va.gov/reports/abr/index.asp. 

Accessed July 29, 2015.

26. Grantham, MAM. Noise-induced hearing loss and 

tinnitus: challenges for the military. In: Le Prell 

CG, Henderson D, Fay RR, Popper AN, eds. NoiseInduced Hearing Loss: Scientific Advances. New 

York, NY: Springer; 2012:27-38.

27. Humes LE, Joellenbeck LM, Durch JSE. Noise and 

Military Service: Implications for Hearing Loss 

and Tinnitus. Washington, DC: The National Academies Press, 2006.

28. Helfer TM, Jordan NN, Lee RB. Postdeployment 

hearing loss in U.S. Army soldiers seen at audiology clinics From April 1, 2003 through March 31, 

2004. Am J Audiol. 2005;14(2):161-168.

29. Wells TS, Seeling AD, Ryan MAK, et al. Hearing 

loss associated with US military combat deployment. Noise Health. 2015; 17(74):34-42.

30. Fausti SA, Wilmington DJ, Gallun FJ, Myers PJ, 

Henry JA. Auditory and vestibular dysfunction associated with blast-related traumatic brain injury. J 

Rehabil Res Dev. 2009;46(6):797-809.

31. Dougherty AL, MacGregor AJ, Han PP, Viirre 

E, Heltemes KJ, Galarneau MR. Blast-related ear 

injuries among U.S. military personnel. J Rehabil 

Res Dev. 2013;50(6):893-904.

32. McIlwain DS, Sisk B, Hill M. Cohort Case Studies 

on Acoustic Trauma in Operation Iraqi Freedom. 

US Army Med Dep J. April-June 2009:14-23.

33. Xydakis MS, Bebarta VS, Harrison CD, Conner JC, 

Grant GA, Robbins AS. Tympanic-membrane perforation as a marker of concussive brain injury in 

Iraq. New Engl J Med. 2007;357(8):830-831.

34. MacGregor AJ, Dougherty AL, Tang JJ, Galarneau 

MS. Postconcussive symptom reporting among 

U.S. combat veterans with mild traumatic brain injury from Operation Iraqi Freedom. J Head Trauma Rehabil. 2013;28(1):59-67.

35. Helfer TM, Canham-Chervak M, Canada S, 

Mitchener TA. Epidemiology of hearing impairment and noise-induced hearing injury among U.S. 

military personnel, 2003-2005. Am J Prev Med. 

2010;38(1):S71-S77.

36. Helfer TM, Jordan NN, Lee RB, Pietrusiak P, Cave 

K, Schairer K. Noise-induced hearing injury and 

comorbidities among postdeployment U.S. Army 

soldiers: April 2003-June 2009. Am J Audiol. 

2011;20(1):33-41.

37. Cave KM, Cornish EM, Chandler DW. Blast Injury 

of the ear: clinical update from the Global War on 

Terror. Mil Med. 2007;172(7):726-730.

38. Walsh DV, Capó-Aponte J, Jorgensen-Wagers, et 

al. Visual field dysfunctions in warfighters during 

different stages following blast and nonblast mTBI. 

Mil Med. 2015;180(2):178-185.

39. Army Pamphlet 40-501: Medical Services Hearing 

Conservation Program. Washington, DC: US Department of the Army; 1998 [obsolete].

Hearing Loss and Tinnitus in Military Personnel

with Deployment-Related Mild Traumatic Brain Injury
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40. Rothman KJ, Greenland S, Lash TL. Modern Epidemiology. 3rd ed. Philadelphia: Lippincott, Williams and Wilkins; 2008.

41. Schairer K. Mild traumatic brain injury and associated effects on the auditory system. Perspect 

Hear Hear Disord Res Res Diagn. 2012;16(1):18-25. 

Available at: http://sig6perspectives.pubs.asha.org/

article.aspx?articleid=1769455. Accessed June 17, 

2016.

42. Yurgil KA, Clifford RE, Riskbrough VB, et al. 

Prospective associations between traumatic brain 

injury and postdeployment tinnitus in active-duty 

Marines. J Head Trauma Rehabil. 2016;31(1):30-39.

43. Shargorodsky J, Curhan GC, Farwell WR. Prevalence and characteristics of tinnitus among US 

adults. Am J Med. 2010;123(8):711-718.

44. Remenschneider AK, Lookabaugh S, Aliphas 

A, et al. Otologic outcomes after blast injury: 

the Boston Marathon experience. Otol Neurotol. 

2014;35(10):1825-1834.

45. Fagelson MA. The association between tinnitus 

and posttraumatic stress disorder. Am J Audiol. 

2007;16(2):107-117.

46. Riddle JR, Smith TC, Smith B, et al. Millennium 

Cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military. J Clin Epidemiol. 

2007;60(2):192-201.

47. Abel SM. Barriers to Hearing conservation programs in combat arms occupations. Aviat Space 

Environ Med. 2008;79(6):591-598.

48. Casali JG, Ahroon WA, Lancaster JA. A field investigation of hearing protection and hearing enhancement in one device: for soldiers whose ears and lives 

depend upon it. Noise Health. 2009;11(42):69-90.

49. Okpala NCE. Knowledge and attitude of infantry soldiers to heraing conservation. Mil Med. 

2007;172(5):520-522.

50. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in 

U.S. soldiers returning from Iraq. New Engl J Med. 

2008;358(5):453-463.

51. Benzinger TLS, Brody D, Cardin S, et al. Blast-related brain injury: imaging for clinical and research 

applications: report of the 2008 St. Louis workshop. 

J Neurotrauma. 2009;26(12):2127-2144.

52. Nomura K, Nakao M, Morimoto T. Effect of smoking on hearing loss: quality assessment and metaanalysis. Prev Med. 2005;40(2):138-144.

53. Dawes P, Cruickshanks KJ, Moore DR, et al. Cigarette smoking, passive smoking, alcohol consumption, and hearing loss. J Assoc Res Otolaryngol. 

2014;15(4):663-674.

Authors

Dr Karch is with the Auditory Protection & Performance 

Division, US Army Aeromedical Research Laboratory, 

Fort Rucker, Alabama.

LTC Capó-Aponte is the Optometry Residency Director, 

Department of Optometry, Womack Army Medical Center, Fort Bragg, North Carolina. He also is a consultant 

to the US Army Aeromedical Research Laboratory, Fort 

Rucker, Alabama.

LTC McIlwain is with the Auditory Protection & Performance Division, US Army Aeromedical Research Laboratorr, Fort Rucker, Alabama.

Mr Lo is with the Laulima Government Solutions, LLC, 

supporting the US Army Aeromedical Research Laboratory, Fort Rucker, Alabama.

Dr Krishnamurti is with the Department of Communications Disorders, Auburn University, Auburn, Alabama.

Dr Staton is with the Auditory Protection & Performance 

Division, US Army Aeromedical Research Laboratory, 

Fort Rucker, Alabama.

Dr Jorgensen-Wagers is with the Traumatic Brain Injury 

Clinic, Landshtul Regional Medical Center, Germany.
64 http://www.cs.amedd.army.mil/amedd_journal.aspx

History of Good Laboratory Practices

New Zealand introduced good laboratory practice (GLP) 

standards in 1972 as the Testing Laboratory Registration Act, which addressed record keeping, animal handling, dosing and observation procedures, equipment 

use, and facilities. Denmark passed a law the same year 

to promote GLPs. In 1975, Senator Edward Kennedy 

and representatives of the Food and Drug Administration (FDA) accused certain research laboratories in the 

United States of serious inadequacies in the execution 

and documentation of preclinical research studies. G. D. 

Searle and Company and Hazelton Laboratories were 

identified as having poor record keeping, inadequate 

data storage, and poor test facility management; performing inadequate personnel training; and committing 

fraud.1

The FDA published final GLP regulations (21 CFR 58) 

in December 1978, directing compliance by June 1979. 

However, a number of investigations were discovering 

serious problems before that regulatory mandate became effective. The scope of the problem reached the 

front pages of newspapers in 1981 when 4 executives 

of Industrial Bio-Test Laboratories (IBT) were indicted 

for providing false data to chemical companies, who in 

turn had presented that data to the US government to 

demonstrate their products were safe for market.2

 The 

findings were alarming because IBT submitted data on 

200 pesticides, of which over 66% were judged invalid 

and only 19% acceptable. At that time, IBT operated the 

largest facility of its kind and performed more than onethird of all toxicology testing in the United States. In addition, IBT was accused of presenting results to chemical 

manufacturers that could not be verified. Newspaper editorials reported high rodent mortality and appalling husbandry conditions that offended public sensitivities and 

confounded research results.3,4 The discoveries resulted 

in congressional hearings. The revelations led to reforms, 

amendments, and clarifications in the regulation of pesticides in the United States and Canada. Three of the IBT 

executives were convicted and sentenced in 1983.5

In January 1986, G. D. Searle scientists submitted a 

document entitled Good Laboratory Practice to the 

FDA and the Pharmaceutical Research and Manufacturers Association of America. Later that year, the FDA 

released proposed regulations on GLPs based on that 

Searle submission and published them in the Federal 

Register. In September 1987, the FDA published the 

Final Rule – Compliance Program Bioresearch Monitoring: Good Laboratory Practices, which incorporated the 

requirement for a quality assurance (QA) department, 

Going GLP: Conducting Toxicology

 Studies in Compliance with

 Good Laboratory Practices

LTC Erica Eggers Carroll, VC, USA

Abstract

Good laboratory practice standards are US federal regulations enacted as part of the Federal Insecticide, Fungicide, and Rodenticide Act (40 CFR Part 160), the Toxic Substance Control Act (40 CFR Part 792), and the 

Good Laboratory Practice for Nonclinical Laboratory Studies (21 CFR Part 58) to support protection of public 

health in the areas of pesticides, chemicals, and drug investigations in response to allegations of inaccurate data 

acquisition. Essentially, good laboratory practices (GLPs) are a system of management controls for nonclinical 

research studies involving animals to ensure the uniformity, consistency, reliability, reproducibility, quality, 

and integrity of data collected as part of chemical (including pharmaceuticals) tests, from in vitro through acute 

to chronic toxicity tests. The GLPs were established in the United States in 1978 as a result of the Industrial 

Bio-Test Laboratory scandal which led to congressional hearings and actions to prevent fraudulent data reporting and collection. Although the establishment of infrastructure for GLPs compliance is labor-intensive and 

time-consuming, achievement and maintenance of GLP compliance ensures the accuracy of the data collected 

from each study, which is critical for defending results, advancing science, and protecting human and animal 

health. This article describes how and why those in the US Army Medical Department responsible for protecting the public health of US Army and other military personnel made the policy decision to have its toxicology 

laboratory achieve complete compliance with GLP standards, the first such among US Army laboratories. The 

challenges faced and how they were overcome are detailed.
October – December 2016 65

The Army Medical Department Journal

the requirement for protocol preparation (ie, a study 

plan), characterization of test and control materials, and 

the requirement to retain specimens and samples.1

 Robinson succinctly describes the significance of this regulatory milestone:

Within 14 years, therefore, GLP moved from an ad hoc 

concept to legally enforceable code, designed to control 

and regulate the quality of laboratory-based operations.1

The Environmental Protection Agency (EPA) encountered similar problems with data it received, and issued 

its draft GLP regulations in 1979 and 1980. The EPA 

published the Final Rules in 1983 in 2 parts, 40 CFR 

160 and 40 CFR 792, which describe GLPs for conducting studies relating to health effects, environmental effects, and chemical fate testing. Additionally, the 

Organization for Economic Cooperation and Development (OECD) issued Principles of GLP in 1992, which 

disseminated information regarding the principles and 

their importance to many countries.

Carson and Dent 6

 summarized the key events in the 

chronology of the implementation of GLP:

1972 New Zealand Testing Laboratory Registration Act

1972 Denmark National Testing Board Act

1976 US-FDA GLP Proposed Rule

1978 US-FDA GLP Final Rule

1979 OECD Expert Group on GLP

1979 US-EPA GLP Proposed Rule, Toxic Substances Control Act (TSCA)

1980 US-EPA GLP Proposed Rule, Federal Insecticide, Fungicide and Rodenticide Act (FIFRA)

1983 US-EPA GLP Final Rules (TSCA and FIFRA)

1987 FDA Final Rule–Compliance Program Bioresearch Monitoring: Good Laboratory 

Practices

Concurrent with the publication of the final regulation, 

the FDA created 606 new positions to monitor biological 

research and began a pilot inspection program to determine baseline skill levels. Major findings in the industry 

included lack of QA departments, failure to test every 

batch of manufactured product, and failure to maintain 

standard operating procedures (SOPs).1

In the year 2000, the FDA issued Toxicological Principles for the Safety Assessment of Food Ingredients: 

Redbook 2000,

7

 with chapters on general guidelines 

for designing and conducting toxicity studies, including GLP, test animals (and housing), test substances, 

experimental design, observations and clinical tests, 

necropsy, and microscopic examination. Currently, 

GLPs are also mandatory to ensure quality and integrity 

of data submitted under the TSCA (40 CFR Part 792) 

and FIFRA (40 CFR Part 160).

Purpose of GLPs

To address and eliminate the concerns expressed in the 

1970s regarding the credibility of toxicity testing, use 

of GLPs creates a clearly traceable audit trail from the 

individual animal data (or petri dish) to the official “raw 

data,” to the initial report, and then to submission of 

the final report to EPA or FDA. Compliance with GLPs 

means ensuring adequately qualified personnel, adequate equipment, a single qualified study director for 

each study, a quality assurance unit, adequate test system and animal care facilities, well characterized test articles, and suitably managed archives of specimens and 

records. The overarching purpose of GLP compliance, 

therefore, is safety and the protection of public health.

The Initiative for GLP Compliance in the Army

Public Health Organization

In 1979, the FDA issued Guidance for Industry which 

established the requirement for GLP adherence for data 

generation to be used in an application for FDA approval. 

An initial GLP inspection was conducted of the Army 

Environmental Hygiene Agency (AEHA) in 1981, at 

which time deficiencies were noted. In September 1990, 

the AEHA submitted a report of acute skin, eye and photochemical irritation to a DoD customer. Unbeknownst 

to the AEHA, the customer submitted that report to the 

FDA as part of a therapeutic substance approval request. 

One month later, the customer informed AEHA that the 

FDA had observed that the report format was inconsistent with GLP regulations and then had decided to inspect AEHA facilities with regard to the conduct of that 

study. In November 1990, the FDA inspected and issued 

a report in June 1991 identifying 19 deficiencies involving receipt and disbursal logs, characterization of the 

purity of test article, incomplete raw data, inadequate 

control animals, and more. The report included a task to 

describe corrective action taken and planned, including 

a timeline for completion. The AEHA acted immediately, and the FDA was satisfied with the corrections executed or planned. From that point forward, the AEHA 

senior leadership invested time and resources to become 

fully GLP-compliant, and issued policy mandating such 

from the Toxicology Division.

The AHEA Chief of Staff in 1991 held quality science 

and quality deliverables among his highest priorities. In 

September of that year, he initiated a quality management system for the AHEA Toxicology Division to take 
66 http://www.cs.amedd.army.mil/amedd_journal.aspx

all measures necessary to establish the infrastructure 

to maintain compliance with GLP standards. This was 

deemed necessary because data from some studies performed by the Division are submitted to the EPA as part 

of applications for product approval. The EPA and FDA 

only approve compounds whose safety data are generated under GLP-compliant conditions.

As early as October 1991, principal investigators and 

other personnel attended GLP training and conducted 

an in-house gap analysis with special assistance by a 

GLP consultant. They identified specific needs for the 

organization, considering SOPs already in place, whether they were adequate, which new SOPs were needed, 

and what management controls were necessary to ensure compliance. Personnel from other divisions with an 

aptitude for quality assurance were reassigned into a nascent Quality Assurance Unit (QAU). In April 1992, the 

Toxicology Division was inspected by an outside consultant for compliance with the EPA GLP under the FIFRA. Additionally, the consultant provided training for 

personnel. Those personnel, in turn, wrote policy memoranda and drafted, evaluated, and established an internal audit program to perform regular self-assessments 

with “teeth” to ensure corrective actions would be taken 

when appropriate. In the past, auditors had occasionally spot-checked study conduct and compared methods 

used with approved animal use protocols, but such examinations were inadequate. With the new QAU, audits 

became much more stringent. Additional inspections in 

June 1992 and again 3 years later were performed to ensure AEHA was maintaining course.

The biggest challenge was to convince the staff of the 

value of the new requirements. Roughly 25% of the personnel recognized the need and supported it. Roughly 

25% of personnel were unconvinced that the increase in 

administrative tasks would have any value in what they 

considered an already functional system of toxicity testing, and roughly 50% of personnel reserved judgment 

until they could see for themselves whether it was worth 

the effort. It required a change in culture, which was 

facilitated by the mandate from senior leadership.

It took 12 to 18 months to establish most of the policies, 

SOPs, and the audit system. Credentialed GLP trainers 

annually trained Toxicology Division personnel. Additionally, the QAU team sought additional training to 

augment their expertise with the standards to ensure 

that SOPs were adequately written and the laboratories 

under their purview were compliant.

From the initial reassignment of duties in September 

1991 to the present, the QAU has grown to 20 personnel who monitor the GLP compliance of today’s Army 

Public Health Center (APHC)* Toxicology Directorate 

(TOX) and oversee quality control for the Laboratory 

Sciences Directorate, Radiation Safety, Animal Care 

staff, Human Protection, and the Institute Animal Care 

and Use Committee (IACUC). The degree of “buy in” 

by affected personnel influences the amount of time it 

takes to successfully comply with GLP. Not every organization will need a multifunction QAU as is presently 

operating at the APHC. The mission will dictate the extent of quality assurance investment necessary.

At APHC-TOX, we routinely use GLPs for toxicity testing of all chemicals, whether or not they fall under the 

purview of the EPA. Provisions of the TSCA, FIFRA, 

and FDA regulations are met to produce data that can 

be submitted at a later date, if required. The last time 

EPA inspectors visited APHC was for a study of a mess 

kit cleaning compound, trichloromelamine, known officially as a field food service disinfectant. A 14-day 

range-finding study and a 90-day subchronic study in 

rats revealed oral toxicity of the substance when ingested. The organization was in full compliance with EPA 

requirements. Currently, GLP compliance is a way of 

life in the Toxicology Directorate. Training of SOPs is 

ongoing and formal GLP training is conducted annually, 

coordinated with another DoD facility that itself is moving toward compliance.

Pros And Cons of “Going GLP”

The disadvantages of implementing GLP standards lead 

to the benefits of such action. The adoption of GLP regulations require training to produce adequately qualified 

personnel (documented as such), adequate facilities 

(verified by inspection), a single qualified study director 

for each study (identified by signature on an official protocol approved by the IACUC), and a QA unit specifically tasked with ensuring compliance with all relevant 

SOPs. Test system facilities must be verified by QA personnel, test articles or items must be adequately characterized, and documents that confirm such characterization maintained. Equipment used during the course of 

a study must be shown to perform as required, may require calibration (and documentation of such calibration 

retained), and be adequately inspected, cleaned, and 

maintained, all with documentation. The SOPs must be 

drafted by subject matter experts, approved by management (not QA), used to train personnel and to properly 

document preventive maintenance of test systems. Every 

*The Army Environmental Hygiene Agency was redesignated as the US Army Center for Health Promotion and Preventive Medicine (USACHPPM) on August 2, 1994. On October 1, 2009, USACHPPM assumed additional responsibilites and was redesignated as the US Army 

Public Health Command, which was subsequently redesignated as the US Army Public Health Center on October 1, 2016.

Going GLP: Conducting Toxicology Studies

in Compliance with Good Laboratory Practices
October – December 2016 67

The Army Medical Department Journal

study is driven by a study protocol/plan with specified 

content approved by the study director, and every study 

is concluded with a comprehensive study report with 

specified content. The disadvantages, therefore, are all 

the work involved and the meticulous documentation 

of that completed work. The resulting benefits are the 

documentation of achievements, well trained personnel, and a smooth-running, efficient organization that 

more consistently produces a high-quality product. To 

document training of personnel on SOPs and to revise 

SOPs, the APHC QAU uses, and therefore TOX uses, 

a MasterControl software package (MasterControl, Inc, 

Salt Lake City, UT). It was selected because it not only 

tracks SOP revisions and training, but provides other 

capabilities as well, such as supply functions, accident/

injury reports, audit reports, and study protocols.

The GLP regulations require documentation of any 

laboratory worksheets, records, memoranda, notes, or 

exact copies of such documents that result from original observations and activities of a nonclinical laboratory study, and are necessary for the reconstruction and 

evaluation of the report of that study. Also required is 

an archive for orderly storage and expedient retrieval of 

all raw data, documentation, protocols/plans, and specimens generated as the result of a nonclinical laboratory 

study. One exception is the pathologist’s working notes, 

including a working spreadsheet, are not considered raw 

data and are not subject to auditing. Only the signed, 

completed pathology reports (and processed tissues) are 

considered raw data subject to audit.8

 This is because of 

the judgment involved in assigning severity scores to lesions, which frequently entails more than one viewing of 

the slides, both unblinded and then blinded, to confirm.

It is obviously good scientific practice to ensure a laboratory maintains properly functioning equipment, qualified personnel, and properly recorded data. Facilities 

around the world, including developing countries, have 

demonstrated the capability to successfully perform 

GLP compliant studies. Some argue, however, these meticulous practices are too painstaking in research that 

is not being submitted to a regulatory agency. Others 

claim that since studies that do not meet these standards 

may be published in peer reviewed scientific journals, 

good science may be performed without GLP compliance. It is also accurate to state that compliance with 

GLP does not assure good science. Since good and bad 

science may be performed in GLP compliant or noncompliant fashion, this argument misdirects the discussion from the reason why GLPs are required: to ensure 

the accuracy of the data collected. Early discovery, 

animal model development, or other research in which 

methods may require frequent adjustment might not fit 

the GLP model. Data and reports of nonclinical safety 

studies, however, are used to make public health decisions; therefore, these studies must be meticulously conducted and recorded to ensure transparency, that is, they 

can be reconstructed from the records to demonstrate 

the integrity of the data. The nature of the test article 

determines the regulating agency and, therefore, the applicable GLP regulations. The FDA is responsible for 

protecting and promoting public health through the regulation and supervision of food safety, tobacco products, 

over-the-counter pharmaceutical drugs (medications), 

vaccines, biopharmaceuticals, blood transfusions, medical devices, electromagnetic radiation emitting devices, 

cosmetics, animal foods and feed, and veterinary products. Under the TSCA, the EPA regulates all commercial 

chemicals and substances (such as lead, formaldehyde, 

asbestos, mercury, and polychlorinated biphenyls), and 

FIFRA requires it to regulate insecticides, fungicides, 

and rodenticides. As Robinson points out:

GLP is not a luxury. It is a necessity for any professional 

laboratory wishing to gain and retain the respect of its 

employees, clients, [and] regulators....1

GLP Compliance as a Lifestyle

How does an organization know when GLP compliance 

has been achieved? Although internal audit processes 

can certainly identify areas where a procedure “misses 

the mark” and recommend corrective action, it is ultimately the FDA or EPA inspectors who have the answers for a given study.

How is GLP compliance maintained? The organization 

continues to follow the SOPs and policies put in place to 

achieve GLP compliance, with continuous monitoring 

by QA personnel, and continuous training and process 

improvement. Each individual engaged in the conduct 

of or responsibility for the supervision of a study shall 

have the education, training, and experience necessary 

to perform the assigned functions.9

 Thus, training is at 

the heart of GLP.

It is important to note that in the United States, GLP 

compliance is ascertained per study. An organization 

itself cannot be certified as GLP-compliant as is done 

in Europe. As illustrated in the Figure, good laboratory 

practices are comparable in the United States and other 

nations, but are not identical.

Going GLP can actually improve efficiency in performing a mission. Currently, the Division of Toxicologic Pathology of the Toxicology Directorate, which performs 

statistical analysis on all data, transfers spreadsheets of 

histologic data to a biostatistician in another directorate who performs Fisher’s Exact test on the data using 
68 http://www.cs.amedd.army.mil/amedd_journal.aspx

Conduct of a 

Study in 

Accordance 

with the 

Protocol

58.130

(a) The nonclinical laboratory study 

shall be conducted in accordance with 

the protocol.

792.130

(a) The study shall be conducted in 

accordance with the protocol.

Section II 8.3.2. 

The study should be conducted in 

accordance with the study plan.

Test System 

Conformity with 

the Protocol

58.130

(b) The test systems shall be monitored 

in conformity with the protocol.

792.130

(b) The test systems shall be monitored 

in conformity with the protocol.

Labeling of 

Specimens

58.130

(c) Specimens shall be identified by 

test system, study, nature, and date 

of collection. This information shall 

be located on the specimen container 

or shall accompany the specimen in 

a manner that precludes error in the 

recording and storage of data.

792.130

(c) Specimens shall be identified by 

test system, study, nature, and date 

of collection. This information shall 

be located on the specimen container 

or shall accompany the specimen in 

a manner that precludes error in the 

recording and storage of data.

Section II 8.3.1. 

A unique identification should be given 

to each study. All items concerning this 

study should carry this identification. 

Specimens from the study should be 

identified to confirm their origin. Such 

identification should enable traceability, 

as appropriate for the specimen and 

study.

Availability of 

Gross Findings

 to Pathologists

58.103

(d) Records of gross findings for 

a specimen from postmortem 

observations should be available to 

a pathologist when examining that 

specimen histopathologically.

792.130

(d) In animal studies where 

histopathology is required, records 

of gross findings for a specimen 

from postmortem observations 

shall be available to a pathologist 

when examining that specimen 

histopathologically.

Manual 

Recording 

of Data

58.130

(e) All data generated during the 

conduct of a nonclinical laboratory 

study, except those that are generated 

by automated data collection systems, 

shall be recorded directly, promptly, 

and legibly in ink. All data entries 

shall be dated on the date of entry 

and signed or initialed by the person 

entering the data.

792.130

(e) All data generated during the 

conduct of a study, except those that 

are generated by automated data 

collection systems, shall be recorded 

directly, promptly, and legibly in ink. All 

data entries shall be dated on the day 

of entry and signed or initialed by the 

person entering the data.

Section II 8.3.3. 

All data generated during the conduct 

of the study should be recorded 

directly, promptly, accurately, and 

legibly by the individual entering the 

data. These entries should be signed or 

initialled and dated.

Changes to 

Mannually 

Recorded 

Data

58.130

(e) Any change in entries shall be 

made so as not to obscure the original 

entry, shall indicate the reason for such 

change, and shall be dated and signed 

or identified at the time of the change.

792.130

(e) Any change in entries shall be 

made so as not to obscure the original 

entry, shall indicate the reason for such 

change, and shall be dated and signed 

or identified at the time of the change.

Section II 8.3.4. 

Any change in the raw data should be 

made so as not to obscure the previous 

entry, should indicate the reason for 

change and should be dated and signed 

or initialled by the individual making 

the change.

Automated 

Recording of 

Data

58.130

(e) In automated data collection 

systems, the individual responsible for 

direct data input shall be identified at 

the time of data input.

792.130

(e) In automated data collection 

systems, the individual responsible for 

direct data input shall be identified at 

the time of data input.

Section II 8.3.5. 

Data generated as a direct computer 

input should be identified at the time 

of data input by the individual(s) 

responsible for direct data entries.

Changes to 

Data Recorded 

by Automated 

Systems

58.130

(e) Any change in automated data 

entries shall be made so as not to 

obscure the original entry, shall 

indicate the reason for change, shall be 

dated, and the responsible individual 

shall be identified.

792.130

(e) Any change in automated data 

entries shall be made so as not to 

obscure the original entry, shall 

indicate the reason for change, shall be 

dated, and the responsible individual 

shall be identified.

Section II 8.3.5. 

Computerised system design should 

always provide for the retention of 

full audit trails to show all changes 

to the data without obscuring the 

original data. It should be possible to 

associate all changes to data with the 

persons having made those changes, 

for example, by use of timed and dated 

(electronic) signatures. Reason for 

changes should be given.

Comparison of GLP Requirements for FDA, EPA and OECD. Adapted from FDA comparison chart.10

Going GLP: Conducting Toxicology Studies

in Compliance with Good Laboratory Practices
October – December 2016 69

The Army Medical Department Journal

statistical packages to deliver to the pathologist incidence tables of findings and resultant P values. The data 

going to the statistician and the tables returning from 

the statistician pass through the QAU auditor to ensure 

data integrity. The demands in labor and time on the 

auditor and on the statistician can add 4-6 weeks to the 

production time of a large pathology report. Purchase of 

a pathology data management software package that is 

fully GLP-compliant meets the requirements for consistency and transparency, and reduces the time required 

for statistical analysis of the histologic data. In 2015, an 

increase in the number and complexity of toxicity studies, new personnel, and new software capabilities on the 

market (eg, a standalone pathology module) drove a reexamination of the feasibility of such a purchase. Market research is being done thoroughly, inviting key local 

players who can ask the most important questions. Purchase of a software solution will significantly enhance 

GLP-compliance and efficiency of pathology support to 

the toxicology mission.

An organization that decides to go GLP may not need 

a policy statement. What may be essential, however, 

is steadfast leadership to change the corporate culture, 

codify the decision, prevent digression, and prioritize 

the investment of resources. Leadership should ensure 

the benefits are kept ahead of forces against change. 

Milestones should be identified and rewarded when 

reached, and leadership should embrace training, assessment, data integrity, and commitment to continuous 

improvement as essential in providing useful products to 

ensure the health of the force and to maintain readiness.

Acknowledgements

I thank Mr Michael P. Kefauver, Chemist and Quality Assurance Unit Auditor, and Mr Gene Sinar, Chief, 

Quality Systems and Regulatory Compliance Office, 

APHC for their provision of historical documents for this 

manuscript as well as their editorial review.

References

1. Robinson K. GLPs and the importance of standard operating procedures. BioPharm Int [serial 

online]. August 1, 2003. Available at: http://www.

biopharminternational.com/glps-and-importancestandard-operating-procedures. Accessed June 30, 

2016.

2. Slade M, Hoffman E. Ideas & trends in summary; 

laboratory official accused of fudging. New York 

Times [archives]. June 28, 1981. Available at: http://

www.nytimes.com/1981/06/28/weekinreview/

ideas-trends-in-summary-laboratory-official-ac

cused-of-fudging.html?scp=216&sq=Deodorant&s

t=nyt. Accessed July 1, 2016.

3. Editorial. The scandal in chemical testing. New 

York Times [archives]. May 16, 1983; Opinion. 

Available at: http://www.nytimes.com/1983/05/16/

opinion/the-scandal-in-chemical-testing.html. Accessed June 30, 2016.

4. Broad WJ. Who tests the product-testing labs?. 

New York Times [archives]. May 22, 1983. Available at: http://www.nytimes.com/1983/05/22/week

inreview/who-tests-the-product-testing-labs.html. 

Accessed July 1, 2016.

5. Schneider K. IBT-guilty: how many studies are 

no good? [internet]. National Resources Defense 

Council. 1983. Available at: http://www.webcita

tion.org/69H25Lrgw. Accessed July 6, 2016.

6. Carson PA, Dent NJ, eds. Good Clinical, Laboratory and Manufacturing Practices: Techniques for 

the QA Professional. Cambridge, UK: The Royal 

Society of Chemistry; 2007.

7. Food and Drug Administration. Redbook 2000: 

Guidance for Industry and Other Stakeholders-Tosicological Principals for the Safety Assessment of 

Food Ingredients. Washington, DC: US Food and 

Drug Administration; July 2000, revised July 2007. 

Available at: http://www.fda.gov/downloads/Food/

GuidanceRegulation/UCM222779.pdf. Accessed 

June 29, 2016.

8. Tuomari D, Elliott G, Kulwich B, Yarrington J, 

Fouillet X, Geoly F, Long P. Society of Toxicologic 

Pathology position on histopathlology data collection and audit trail: compliance with 21 CFR Parts 

58 and 11. Toxicol Pathol. 2004;32(1):122-123.

9. Morton D, Demp RK, Francke-Carroll S, et al. Best 

practices for reporting pathology interpretations 

with the GLP toxicology studies. Toxicol Pathol. 

2006;34:806.

10. Food and Drug Administration. Comparison Chart 

of FDA and EPA Good Laboratory Practice (GLP) 

Regulations and the OECD Principles of GLP. 

Washington, DC: US Food and Drug Administration; June 2004:33-34. Available at: http://www.fda.

gov/downloads/ICECI/EnforcementActions/Bio

researchMonitoring/UCM133724.pdf. Accessed 

June 30, 2016.

Author

LTC Carroll is Chief, Division of Toxicologic Pathology, 

Toxicology Directorate, US Army Public Health Center, 

Aberdeen Proving Ground, Maryland.
70 http://www.cs.amedd.army.mil/amedd_journal.aspx

The above scenario is an actual event experienced by 

author J. Topinka. Today, 4 years later, there is a lactation room only several yards from where the junior 

officer approached that professor. In addition, in February 2016, the Defense Health Headquarters (DHHQ) 

published (internal) information on “DHHQ Lactation 

Support” and the 3 lactation rooms that provide private, clean spaces for nursing mothers and their babies. 

The rooms have a refrigerator for storing breast milk, 

a handwashing sink, pump cleaning supplies, comfortable chairs, and resource information. Volunteers have 

even provided blankets, pillows, white noise machines, 

privacy screens, resource materials, and other supplies.

While there has obviously been a great deal of change in 

breastfeeding policy since March 2010 when the Patient 

Protection and Affordable Care Act (PPACA), Pub L No. 

111-148 was signed into law, how does current policy 

and the law apply to female service members at a time 

when they are taking on more and more responsibilities 

and duties within the military? This article endeavors to 

answer that question and provide military and medical 

leaders, as well as clinicians, guidance on how to deal 

with the needs of nursing service members and address 

outstanding issues that will undoubtedly be debated in 

the future.

The Fundamentals

Constitutional Right?

Even before state or federal laws supported breastfeeding, courts throughout the country made an effort to protect nursing mothers. One federal case, Dike v School 

Board of Orange County Florida, 650 F2d 783 (5th Cir 

1981), exemplifies these efforts. In Dike, a kindergarten 

teacher, Janice Dike, breastfed her baby in a private, 

locked room at her school until the school’s principal 

informed her that the practice violated a regulation. She 

tried to pump, but her baby refused the breast milk from 

a bottle. She then tried to get permission to breastfeed 

off the school campus but was refused. After the district 

court dismissed the case, she appealed to the 5th Circuit 

Court. While the Circuit Court held that “...her interest in nurturing her child by breastfeeding is entitled in 

some circumstances to constitutional protection against 

state infringement,” the aftermath of the decision did 

not go in Janice Dike’s favor when the case went back 

to the trial court.

State Laws

Prior to 2010, there were, surprisingly, no federal laws 

that gave legal protection to mothers who wanted to 

breastfeed or pump for their babies. On the other hand, 

state laws on breastfeeding have existed in some form 

or another since 1995. In their 2011 article,1

 Murtagh 

and Moulton provided a solid analysis of state laws on 

breastfeeding. While these state laws may not have had 

much effect on the rules and regulations of the military 

prior to 2010, they were in effect in cities and communities where service members lived and shopped, thereby 

influencing military personnel and their families.

According to Murtagh and Moulton,1

 23 states and 2 territories had enacted breastfeeding statutes by 2009 that, 

for the most part, focused on 3 main areas: break times, 

private locations, and workplace breastfeeding friendliness. Twenty-one of those state laws concentrated on 

An Expression of Change:

 Breastfeeding in the Military

Joseph B. Topinka, JD, MHA, MBA, LLM

Linda R. Turner, MLS

Kim Lee, PhD, MSHP, PT

MAJ Jodi Brown, AN, USA

Scenario

A junior US Army nurse attending the Basic Officer Leadership Course (BOLC) comes into the office of 

a US Army Baylor Graduate School professor that is near the main auditorium where her BOLC courses 

are being taught. She explains to the professor that she needs to express herself. The professor, open to an 

academic discussion with anyone, indicates to the junior officer that she can express herself anywhere in 

the building, especially in such an academic environment as the Army’s Academy of Health Sciences. In 

response, the young nurse teaches the professor a lesson he will never forget. First, her comment about 

expression refers to the expression of breast milk. Second, she tells the professor there is no place available 

for her to express except the washroom, which is neither an appropriate nor healthy option. The professor 

allows the junior officer to use his office in private.
October – December 2016 71

The Army Medical Department Journal

breastfeeding break times, with 19 on private locations. 

Eight prohibited breastfeeding related discrimination in 

the workplace, and three encourage “infant friendly” or 

“mother friendly” workplaces.

A current, very detailed list of state laws on breastfeeding can be found on the National Council of State Legislatures website (http:/ncsl.org). A review of this list 

shows that some states allow public breastfeeding. Unfortunately, many do not have any enforcement mechanisms such as penalties for violating the rights of nursing 

mothers. In addition, a careful review reveals that only 

a few states specifically state that breastfeeding is not 

indecent conduct. Unfortunately, in those states without 

such a provision, a nursing mother could theoretically 

be subject to prosecution.

In short, the states vary in their legal handling of breastfeeding, and that variance should at least be considered 

by members of the military who are assigned within 

those jurisdictions and who live in communities outside of a military reservation. While state breastfeeding 

laws can certainly influence the rules and regulations of 

military facilities, those facilities ultimately fall under 

federal control and the federal, jurisdictional authority 

of the commanding officer of that installation.

Federal Laws

The PPACA was significant in the evolution of breastfeeding laws. As seen below, Section 4207 of the Act, 

which amended the Fair Labor Standards Act of 1938, 

codified at 29 USC 4207, gave working nursing mothers 

significant rights:

(r) Reasonable break time for nursing mothers

(1) An employer shall provide

(a) a reasonable break time for an employee to 

express breast milk for her nursing child for 1 year 

after the child’s birth each time such employee 

has need to express the milk; and

(b) a place, other than a bathroom, that is shielded 

from view and free from intrusion from coworkers and the public, which may be used by an employee to express breast milk.

(2) An employer shall not be required to compensate 

an employee receiving reasonable break time under 

paragraph (1) for any work time spent for such purpose.

(3) An employer that employs less than 50 employees 

shall not be subject to the requirements of this 

subsection, if such requirements would impose an 

undue hardship by causing the employer significant 

difficulty or expense when considered in relation to 

the size, financial resources, nature, or structure of the 

employer’s business.

(4) Nothing in this subsection shall preempt a State law 

that provides greater protections to employees than the 

protections provided for under this subsection.

Murtagh and Moulton note in their article that the law 

is significant for 2 reasons, and we agree. First, the law 

will most likely promote better public health by improving nursing mothers’ ability to express milk. Second, in using the Fair Labor Standards Act, Congress 

made breastfeeding an “integral part of the nation’s 

labor laws.” We also believe that the law clarifies the 

minimal requirements of a private area to express breast 

milk and a reasonable break time to express breast milk 

that cannot be denied by anyone, anywhere, in any jurisdiction, state or federal. Technically, however, the 

law only applies to employees who are covered by the 

act’s overtime provisions under 29 USC 213 (generally 

nonexecutive, hourly employees). Finally, we think that 

the last section of the law could yield discussions in the 

future should a state law be more protective of a nursing 

mother’s rights.

In addition to Section 4207, we find it interesting that 

there is not much written on Pub L No. 108-109, Section 

629, Division F, Title VI, which was passed on January 

23, 2004 and now codified at 41 CFR Chptr 102-74-426, 

titled “May a woman breastfeed her child in a Federal 

building or on Federal property?” According to the language from the CFR noted below, the answer is yes:

Public Law 108-199, Section 629, Division F, Title VI 

(January 23, 2004), provides that a woman may breastfeed her child at any location in a Federal building or on 

Federal property, if the woman and her child are otherwise authorized to be present at the location.

In states that do not include such provision in their laws, 

Pub L No. 108-109 could create conflict in federal facilities such as post offices and courthouses and on military 

reservations. Like many of the state laws that have such 

provisions for public breastfeeding, however, this law 

does not have any enforcement provision.

US Military Service Policies

After the passage of the PPACA, author L. Turner wrote 

a small article regarding breastfeeding for the October 

2010 issue of the US Army Medical Command’s Mercury.2

 At the time, she and her associates believed that 

Section 4207 of the PPACA was just the beginning of 

change for the military in terms of breastfeeding policy. 

While the section had public health in mind, it was really 

an instrument of labor law and therefore may not technically apply to the military. However, we believe it was 
72 http://www.cs.amedd.army.mil/amedd_journal.aspx

an impetus to the policies that all the military services, 

including the US Coast Guard, have implemented.

Paragraph 4.15 of Air Force Instruction 44-102 3

 addresses the use of a private, clean area for military expression and specifies that restrooms are not appropriate. Supervisors are encouraged to work with a nursing 

mother to ensure her work schedule allows 15-30 minutes every 3-4 hours to pump breast milk.

Section 15 of Marine Corps Order 5000.12E 4

 notes that, 

at a minimum, the servicewoman should be afforded the 

availability of a clean, secluded space (not a toilet space) 

with ready access to a water source for the purpose of 

pumping breast milk. Command involvement is essential, and supervisors and nursing mothers will collaborate to keep to a minimum the amount of time required 

for milk expression.

Section 106 of OPNAV Instruction 6000.1C 5

 stipulates 

that a commanding officer in the Navy shall ensure the 

availability of a private, clean room for expressing breast 

milk. There should be ready access to running water 

and refrigeration for safe storage of breast milk. The 

policy also addresses breastfeeding infants during duty 

hours on a case-by-case basis but granting such permission should not be a reason for granting excessive time 

for meals or from work. The Navy goes one step further 

through its Bureau of Medicine and Surgery Instruction 

6000.14A6

 which provides guidance for Navy Medical 

Department personnel at Navy military treatment facilities. This is an excellent resource for clinicians and 

administrators, especially those in a joint environment.

US Coast Guard Command Instruction 1000.9 7

 provides great detail in Section 7 concerning a lactation 

facility, storage, and lactation breaks. The policy is one 

of flexibility and support from the commanding officer. 

The policy, as with the Navy’s, includes a case-by-case 

policy for requests for breastfeeding infants during duty 

hours.

Army Directive 2015-438

 describes the US Army’s 

policy for a space with access to a safe water supply, 

electricity, a flat surface, and a locking door. The space 

may not be a restroom. No time requirement for pumping is specified in the policy, but it does recommend 15 

to 30 minute breaks 2 to 3 times a day. Like the Navy’s 

Bureau of Medicine, the Army’s Office of the Surgeon 

General and the US Army Medical Command issued 

OTSG/MEDCOM Policy Memo 16-005,

9

 which provides 

comprehensive guidance to Army healthcare facilities 

on the implementation of breastfeeding policies. It is a 

great resource for medical leaders, especially those in a 

joint environment. The memo includes a sample work 

plan policy, a sample “Mother Friendly” Workplace 

Breastfeeding Schedule Request, and a sample infant 

feeding policy standard operating procedure.

Military Leadership and Organizational

Culture Implications

The scenario presented at the beginning of this article 

includes examples of leadership at an individual level, 

but has more broad implications of leadership relative to 

the organizational culture of each of the branches of the 

military. In this scenario, the professor demonstrated individual servant leadership by first serving the privacy 

needs of the junior officer. By putting her needs first, he 

removed barriers for the junior officer and also empowered her to commit not only to her family, but further 

commit to her branch of service and the public. He not 

only demonstrated individual leadership, but he distributed leadership by allowing the junior officer to meet 

the needs of her family and to meet the needs of her 

duties. Others have demonstrated positive correlation 

between associate engagement and loyalty to the organization and between work place policies supporting work 

life balance.10,11 Leaders serving to support work life 

balance and empowerment increase associates’ engagement and then subsequent loyalty to the organization.

Another inference can be drawn from the perspective 

of the leadership potential of the junior officer. Generally, mothers committed to the principle of breastfeeding have equal commitment to their workplace roles and 

a commitment to leadership. A commitment to breastfeeding parallels with high commitment to principled 

leadership. The professor further promoted the junior 

officer’s commitment to her role and the community 

on behalf of the military and to her duties as an officer. 

From a perspective of executive leadership, a woman in 

a role of promoted leadership makes an intentional decision and commitment to do what is best for her family 

by committing to breastfeeding in conjunction with the 

demands of the organization. It is not always easy or 

convenient. She makes the conscious choice to lead in 

this way. Her commitment to her family and the health 

of the baby can also be extrapolated to how she commits 

to those whom she serves in her executive leadership 

role.

The professor in the scenario reinforced not only the 

junior officer’s commitment to her family, but also 

supported one of the policy statements established by 

the American Academy of Pediatrics (AAP) on behalf 

of community leadership. The AAP has established a 

positive correlation of increased health benefits to both 

the infant and mother from breastfeeding. These health 

An Expression of Change: Breastfeeding in the Military
October – December 2016 73

The Army Medical Department Journal

benefits for the mother from the perspective of employment include decreased absenteeism related to infant 

illnesses; improved physical recovery after childbirth; 

decreased risk of chronic diseases such as rheumatoid 

arthritis, cardiovascular disease, and cancer; and decreased risk of postpartum depression, imputing an 

economic benefit to the United States of $13 billion per 

year.12,13

Contemporary leadership theories and best practices 

have originated from military leadership training and 

examples throughout history. The military branches 

have consistently modeled leadership in so many areas. 

In the Army’s Strategic Vision,14 the Army of 2025 and 

beyond will “leverage cross-cultural and regional experts” to conduct its operations across the globe. In this 

same Vision statement, the Army states that:

...it will consist of a balanced, versatile mix of scalable, 

expeditionary forces,...composed of agile and innovative institutions, solders, and civilians...with trusted professionals who strengthen the enduring bonds between 

the Army and the people it serves.

Versatility, balance, and innovation are all key concepts 

included in the Army’s 2015 Vision of the Army in 2025 

and beyond.

The Air Force Vision15 states that it will be a “trusted 

and reliable joint partner with our sister services known 

for integrity in all of our activities....” In addition, the 

Air Force Vision states that those serving in the Air 

Force will “excel as stewards of all Air Force Resources.”

Ray Mabus, US Secretary of the Navy, writes on behalf 

of the Navy’s “Innovation Vision” that innovation includes changing the way that all personnel in the Navy 

think, challenging outdated assumptions, and removing 

bureaucratic processes that prevent great ideas from becoming reality.” 16 With these formal vision statements 

seemingly embracing the concepts of agility and innovation for balanced workforce of professionals, does 

the military not have the opportunity to support agility, 

balance, innovation, and leadership in workplace culture with such policies as breaks for breastfeeding? One 

must ask; are the practices of notsupporting “expression” 

counter to the professed Vision of the military branches? 

Organizational culture is only as consistent and stable 

as the behavioral and policy practices throughout.

Unfinished Business

We believe that each branch of military service has 

made great strides in developing and implementing service policies for breastfeeding. In general, the policies 

mirror 29 USC 207(r)(1) in that they provide at least a 

reasonable break time for a service member to express 

break milk and they require some place other than a 

bathroom that is shielded from view and free from intrusion by coworkers and the public.

Some issues remain, however, which we think must 

eventually be addressed. First, we are aware that breastfeeding in public on federal property remains open for 

debate. The provision of 41 CFR Chptr 102-74-426 described earlier is, on its face, straightforward. But how 

does it apply on a military reservation where uniformity 

is key and professional appearance and good order and 

discipline are enforced? In one recent case, a US Army 

command had to withdraw a policy that required nursing mothers to nurse their infants “discreetly” and cover 

themselves. In another case, an Air Force commander 

rescinded his breastfeeding policy that required nursing 

mothers to leave the area if they refused to use a private 

room or a nursing cover. The authors do not have a magical solution except to say that command flexibility will 

be key, and a cultural modification may be necessary to 

fit within the parameters of the law.

Second, we wonder about the provision in 29 USC 207(r)

(4) presented earlier that addresses more prescriptive 

protections resulting from future state laws. What if a 

particular state affords a nursing mother more rights 

than are afforded to her on the local military installation? Will an exception to policy be implemented for the 

installation so that its policies can be consistent with the 

laws of the local communities? What if the nursing service member works in leased office space? The hypotheticals are numerous, but they are worth discussing as 

an expression of change.

Conclusion

Hopefully, this article will educate many and stimulate 

debate among others. Change is inevitable, especially 

when public health is at stake; and the law is often the 

avenue through which change is made. As David Suzuki 

wrote:

A baby nursing at a mother’s breast...is an undeniable 

affirmation of our rootedness in nature.17

The law and policy on breastfeeding will eventually 

catch up to nature, even in the military. With approximately 14% of the active-duty being women (15.3% of 

officers are women), the military has the opportunity to 

not only “catch up” to public health and policy recommendations, but also has the duty to lead in workplace 

practices honoring the history and culture of leadership 

as demonstrated in the past.18,19
74 http://www.cs.amedd.army.mil/amedd_journal.aspx

References

1. Murtagh L, Moulton AD. Working mothers, 

breastfeeding, and the law. Am J Public Health. 

2011;101(2):217-223. Available at: http://www.ncbi.

nlm.nih.gov/pmc/articles/PMC3020209/. Accessed 

July 11, 2016.

2. Turner L. Laws give breastfeeding rights to mothers nursing in public places. The Mercury [serial online]. October 2010:8. Available at: http://

cdm16379.contentdm.oclc.org/cdm/singleitem/col

lection/p16379coll1/id/5569/rec/36. Accessed July 

12, 2016.

3. Air Force Instruction 44-102: Medical Care Management. Washington, DC: US Department of 

the Air Force; March 17, 2015. Available at: http://

static.e-publishing.af.mil/production/1/af_sg/pub

lication/afi44-102/afi44-102.pdf. Accessed July 11, 

2016.

4. Marine Corps Order 5000.12E: Marine Corps 

Policy Concerning Pregnancy and Parenthood. 

Washington, DC: Headquarters, US Marine Corps; 

December 8, 2004. Available at: http://www.

marines.mil/Portals/59/Publications/MCO%20

5000.12E%20W%20CH%201-2.pdf. Accessed July 

11, 2016.

5. OPNAV Instruction 6000.1C: Navy Guidelines 

Concerning Pregnancy and Parenthood. Washington, DC: US Department of the Navy; July 14, 

2007. Available at: http://www.jag.navy.mil/distrib/

instructions/OPNAV6000.1CPregnancyandParent

hood.pdf. Accessed July 11, 2016.

6. Bureau of Medicine and Surgery Instruction 

6000.14A: Support of Servicewomen in Lactation 

and Breastfeeding. Falls Church, VA: Bureau of 

Medicine and Surgery; August 27, 2014. Available at: 

http://www.med.navy.mil/directives/ExternalDir

ectives/6000.14A.pdf. Accessed July 11, 2016.

7. US Coast Guard Command Instruction 1000.9: 

Pregnancy in the Coast Guard. Washington, DC: 

US Department of Homeland Security; September 

29, 2011.

8. Army Directive 2015-43: Revised Breastfeeding 

and Lactation Support Policy. Washington, DC: US 

Department of the Army; November 10, 2015.

9. OTSG/MEDCOM Policy Memo 16-005: Breastfeeding and Lactation Support Policy. JBSA Fort 

Sam Houston, TX: US Army Medical Department; 

January 21, 2016. Available at: http://www.army.

mil/standto/archive_2015-10-13/?s_cid=standto. 

Accessed July 11, 2016.

10. Angeletti MA. Workplace lactation program: a 

nursing friendly initiative. J Health Hum Serv 

Admin. 2008,31(2):223-239. Available at: http://lib

proxy.txstate.edu/login?url=http://search.proquest.

com.libproxy.txstate.edu/docview/199979191?acco

untid=5683. Accessed July 12, 2016.

11. Swarnalatha C, Prasanna TS. Leveraging employee engagement for competitive advantage: 

strategic role of HR. Review of HRM. 2013;2:139-

148. Available at: http://search.proquest.com/open

view/1c48b282b6679a7410563cfb4142e234/1?pqorigsite=gscholar. Accessed July 12, 2016.

12. American Academy of Pediatrics. Breastfeeding 

initiatives [internet]. Available at: https://www2.

aap.org/breastfeeding/PolicyOnBreastfeeding.

html. Accessed July 12, 2016.

13. Johnston M, Landers S, Noble L, Szucs K, Viehmann L. Breastfeeding and the use of human milk. 

Pediatrics. 2012;129(3):e827-e841. Available at: 

http://pediatrics.aappublications.org/content/129/3/

e827.full#T1. Accessed July 12, 2016.

14. US Army. The Army Vision: Strategic Advantage 

in a Complex World [internet]. Available at: http://

army.mil/e2/rv5_downloads/info/references/the_

army_vision.pdf. Accessed July 12, 2016.

15. US Air Force. Air Force Mission [internet]. Available at: http://www.af.mil/AboutUs.aspx. Accessed 

July 12, 2016.

16. US Navy. Department of the Navy Innovation 

Vision [internet]. 2015:pic2. Available at: http://

navylive.dodlive.mil/files/2015/04/Module-1_v13_

LoRes_3.pdf. Accessed July 12, 2016.

17. Inspiring Quotes website. Available at: http://www.

inspiringquotes.us/quotes/bKR1_pSsQi3Dh. Accessed July 12, 2016.

18. CNN Staff. By the numbers: Women in the U.S. 

military. CNN US [serial online]. January 24, 2013. 

Available at: http://www.cnn.com/2013/01/24/us/

military-women-glance/. Accessed July 12, 2016.

19. Statistic Brain Research Institute. Demographics 

of Active Duty U.S. Military [internet]. November 

12, 2015. Available at: http://www.statisticbrain.

com/demographics-of-active-duty-u-s-military/. 

Accessed July 12, 2016.

Authors

Mr Topinka is an assistant professor in the School of 

Health Administration at Texas State University, San 

Marcos, TX, where he has taught courses in various topics including employment and public health law.

Ms Turner is a Health System Specialist with the Clinical 

Performance Assurance Directorate, US Army Medical 

Command, Fort Sam Houston, Texas.

Dr Lee is Graduate Programs Director and an assistant 

professor in the School of Health Administration at Texas State University, San Marcos, TX, where she teaches 

courses in various areas including strategic management 

and supervisory management.

MAJ Brown is a staff officer at the Army Public Health 

Center, Aberdeen Proving Ground, MD.

An Expression of Change: Breastfeeding in the Military
October – December 2016 75

On October 14, 2014, The New York Times published the 

first part of an in-depth exposé, “The Secret Casualties 

of Iraq’s Abandoned Chemical Weapons,”1

 initiating a 

landslide reaction and innovative response by the Department of Defense (DoD). The article alleged that: 

From 2004 to 2011, American and American-trained 

Iraqi troops repeatedly encountered, and on at least six 

occasions were wounded by, chemical weapons remaining from years earlier in Saddam Hussein’s rule.1

The investigation contained eyewitness accounts by 17 

service members and 7 Iraqi police officers claiming 

exposure to aging chemical weapons abandoned years 

earlier, pointing out that the weapons were not part of an 

active arsenal during the Iraq war; they were remnants 

from Iraq’s arms program in the 1980s during the IranIraq war. The New York Times also asserted the US government, specifically the DoD, kept secret the fact that 

these troops were being injured as they stumbled across 

aged chemical weapons that Saddam Hussein had built 

for his war with Iran, stating that the “[American government]...failed to prepare its troops and medical corps 

for the aged weapons it did find.” Further:

The American government withheld word about its discoveries even from troops it sent into harm’s way and 

from military doctors. The government’s secrecy, victims and participants said, prevented troops in some of 

the war’s most dangerous jobs from receiving proper 

medical care and official recognition of their wounds.

Perhaps most disappointing was the article’s allegation 

that “[n]one of the veterans were enrolled in long-term 

health monitoring.”

A March 25, 2015 New York Times article, “Veterans 

Hurt by Chemical Weapons in Iraq Get Apology,” reported an apology Under Secretary of the Army Brad 

Carson offered for the DoD mishandling of past cases.2

As described in the article, the DoD acknowledged that 

Chemical Weapons Exposures in Iraq:

 Challenges of a Public Health Response

 a Decade Later

Coleen Baird, MD, MPH LTC Joseph Llanos, MC, USA

MAJ Raul Mirza, MC, USA Joseph Abraham, ScD

Jessica Sharkey, MPH Charles McCannon, MD, MPH

Ron Teichman, MD, MPH Jack Heller, PhD

MAJ Romarius Longmire, MC, USA Carole Tinklepaugh, MD, MPH

Deanna Harkins, MD, MPH COL William Rice, MC, USA

Abstract

An October 14, 2014 article in The New York Times reported that the US Department of Defense (DoD) concealed, for nearly a decade, circumstances surrounding service members’ exposure to chemical warfare agents 

(CWA) while deployed to Iraq in support of Operations Iraqi Freedom and New Dawn from March 13, 2003, to 

December 31, 2011, and alleged failure of the DoD to provide expedient and adequate medical care. This report 

prompted the DoD to devise a public health investigation, with the Army Public Health Center (Provisional) 

as the lead agency to identify, evaluate, document, and track CWA casualties of the Iraq war. Further, the 

DoD revisited and revised clinical guidelines and health policies concerning CWA exposure based on current 

evidence-based guidelines and best practices.

A US Army chemical warfare specialist examines potentially 

hazardous materiel discovered in an abandoned Iraqi chemical munitions factory, Camp Taji, Iraq, circa 2013. Photo courtesy of SSG Ryan Jacobsma, US Army.
76 http://www.cs.amedd.army.mil/amedd_journal.aspx

the military had not followed its own policies for caring for troops exposed to old and abandoned chemical 

munitions, and that the Pentagon had failed to follow-up 

thoroughly. The DoD Uniformed Services also agreed 

to consider awarding Purple Heart medals, which may 

be awarded for injuries requiring medical treatment that 

are a result of enemy action,3 to those exposed to makeshift bombs made from chemical weapons. Mr Carson 

further stated, “My ambition, and what I am committed 

to, is to make sure that any person who was exposed 

to a weaponized chemical or a chemical weapon is addressed through this process.” He explained that, under the new guidelines, Veterans identified as possibly 

having suffered exposure to a chemical weapon will be 

contacted by their respective military service branch, 

evaluated in a structured interview, and in some cases, 

invited for a full medical examination. The Veterans 

will also be provided with documentation of their exposure and have their medical records updated accordingly. This information, Mr Carson promised, will also 

be shared with the Department of Veterans Affairs (VA) 

to help Veterans receive follow-up care and/or submit 

claims.2

 Following the October 2014 New York Times

article, DoD leadership formed a working group, under 

the direction of Under Secretary Carson, and developed 

an investigation centered on 4 objectives:

1. identify, contact, and evaluate service members 

and Veterans for possible exposure to chemical 

warfare agents (CWA);

2. offer and provide service members and Veterans 

with likely or confirmed CWA exposure a medical 

exam, if appropriate;

3. document these efforts in the Defense Occupational and Environmental Health Readiness System (DOEHRS) and individual service treatment 

records and ensure the VA is informed of these 

findings, and;

4. consider appropriate recognition for service members and Veterans with injuries resulting from 

likely or confirmed CWA exposure.4

The working group designated the Army Public Health 

Center (Provisional) (APHC(P)) as the DoD lead agency 

for the identification of service members potentially exposed to weaponized chemical agents through the concept of a public health investigation.

Further, the working group adopted a definition for 

CWAs derived from the Chemical Weapons Convention. 

As such, chemical exposures of concern included any 

toxic chemical listed on Schedule 1 or any toxic chemical 

when applied as a method of warfare (eg, incorporated 

into a munition or device specifically designed to cause 

death or other harm through the release of the toxic 

chemical during the employment of the munition or device).5

 Principally, this included, among other substances, nerve agents, mustard agents, and chlorine.

Clinical Effects of Mustard

Sulfur mustard is a blister agent. Signs and symptoms 

of sulfur mustard exposure normally do not occur immediately thereafter.6(pp204-212),7,8 Instead, they manifest 2 

to 48 hours following exposure. The areas of involvement include exposed skin, eyes, and the respiratory 

tract, usually when it has vaporized due to temperature. 

Tender (or thin) skin, mucous membranes, and perspiration-covered skin are more sensitive to its effects. More 

severe exposure may involve the gastrointestinal tract, 

the central nervous system (CNS), and the hematologic 

system.7

 The extent of physiologic damage depends on 

the route and intensity of exposure. Effects from liquid 

mustard manifest sooner than effects from mustard gas. 

In mild to moderate cases, blisters occur 2 hours and 

up to 18 hours after the appearance of skin redness or 

erythema, which typically occurs 4 to 8 hours following exposure, but can occur one to 24 hours after exposure. The erythema may be accompanied by an itchy 

sensation (pruritis) and painful burning. The vesicles do 

not contain sulfur mustard and will not cause secondary contamination. In severe cases, vesication is more 

severe, followed by areas of necrosis. Systemic health 

effects include fever, malaise, prostration, and emesis. 

With ocular exposure, the onset of lacrimation, irritation, pruritis, burning, blepharospasm, and possible miosis occurs within 4 to 12 hours. With higher levels of 

exposures to the eye, onset of symptoms occurs within 

3 to 6 hours. In addition to the above, there is increased 

erythema, eyelid edema, and moderate pain. With severe exposures, usually due to liquid mustard, the onset 

occurs within one to 2 hours. In addition to the above, 

increased eyelid edema, painful photophobia, cornea ulceration, severe pain, and blindness may occur.

Mild inhalation (respiratory) exposures will manifest 

within 2 to 24 hours with rhinorrhea, sneezing, epistaxis, hoarseness progressing to “toneless” voice, barking 

cough, anosmia, wheezing, and dyspnea in smokers and 

asthmatics, and, sometimes, nasal or sinus pain.6(pp204-212)

More severe exposures manifest within 2 to 6 hours. In 

addition to the above, there is acute inflammation of 

the upper and lower airways, necrosis of the respiratory epithelium, possible obstruction of the upper and/

or lower airways secondary to pseudomembranous formation, airway occlusion from inflamed and necrotic 

cells, and death secondary to pneumonia. Other organ 

systems may be affected by other routes or increased 

Chemical Weapons Exposures in Iraq:

Challenges of a Public Health Response a Decade Later
October – December 2016 77

The Army Medical Department Journal

severity of exposure.7 The symptoms of ingestion exposure include nausea, emesis, abdominal pain, diarrhea, 

possible chemical burns of the gastrointestinal tract, 

and prostration. Acute CNS effects, such as CNS excitation and seizures, occur only following very severe 

exposure.6(pp204-212) In addition to being a vesicant, sulfur mustard is also an alkylating agent. Absorption into 

the body can injure the bone marrow, lymph nodes, and 

spleen, resulting in leukopenia and immunosuppression.

Clinical Effects of Sarin

Signs and symptoms of sarin exposure usually occur 

within seconds to hours following a mild or moderate 

dose. Symptoms manifest within seconds to minutes after exposure to sarin gas while the onset of symptoms 

following exposure to liquid sarin may take up to 18 

hours.6(pp142-154) An exposed individual can experience 

one or more of the following: rhinorrhea, blurred vision, 

lacrimation, miosis, eye pain, blurred vision, excessive 

salivation, cough, chest tightness, tachypnea, diarrhea, 

abdominal pain, nausea and/or emesis, polyuria, confusion, drowsiness, weakness, headache, bradycardia, 

tachycardia, muscle twitching, hyperhidrosis, hypotension, or hypertension.6(pp142-154),7 Exposure to a large sarin dose may result in more deleterious health effects 

including loss of consciousness, paralysis, seizures, and 

respiratory failure, which may lead to death.6(pp142-154),7,8

Elements of the CWA Investigation

Current and former service members were assigned to 

one of 4 cohorts, depending on the methodology which 

led to their identification as having been exposed to 

CWAs.4,9 The first cohort included those 26 service members and Veterans identified in the October 2014 New 

York Times article.1

 Seventeen Soldiers, 6 Marines, and 

3 Navy personnel were identified as exposed through 

contact with old munitions. As APHC(P) gathered contact information and contacted these individuals, it was 

determined that efforts should be made to identify the 

units of service members and Veterans specifically identified in media reports, and assess whether other unit 

members were potentially exposed; the identified 244 

potentially exposed personnel formed Cohort 2. Further, 

service members and Veterans identified upon review 

of Post-Deployment Health Assessments (PDHA) or 

Post-Deployment Health Re-Assessments (PDHRA) as 

having been exposed or potentially exposed to CWAs in 

Iraq during Operations Iraqi Freedom and New Dawn 

at any time after March 19, 2003, through December 

31, 2011, were included as Cohort 3.4,9,10 The PDHA/

PDHRA forms are completed when service members 

redeploy and answer a series of questions about current health, changes in health, and deployment-related 

exposure concerns. The form has a question regarding 

potential exposure to chemical, biological, or nuclear 

agents as well as radiation. If this multipronged question is answered in the affirmative, the service member 

is supposed to elaborate, and the healthcare provider reviewing the form should discuss this with the service 

member. Unfortunately, details of the exposure or the 

discussion are not evident on the forms, so the forms 

for all redeployed service members during the time period were searched for key words and assessed for inclusion in Cohort 3. This cohort was expanded to include 

service members and Veterans identified in operational 

reports as having been exposed to weaponized toxic industrial chemicals (also considered CWA) at any time 

from March 19, 2003 through December 31, 2011.9

Operational records regarding exposure incidents during this period remained classified and so use of this 

information for unclassified purposes required coordination between APHC(P) and US Central Command 

intelligence. The last cohort, Cohort 4, included service 

members and Veterans who self-reported exposure or 

potential exposure to CWAs while deployed to Iraq in 

support of Operations Iraqi Freedom and New Dawn at 

any time from March 19, 2003 through December 31, 

2011.4,9 Two weeks following the first New York Times

article,1

 the DoD made a hotline available to individuals who wished to report CWA exposure. This was the 

Office of the Deputy Assistant Secretary of Defense for 

Force Health Protection and Readiness hotline (1-800-

497-6261). Although this hotline existed prior to this 

investigation and receives calls on a number of topics, 

it was specifically publicized to Veterans and service 

members starting on October 31, 2014, to report CWA 

exposures.

The review process varied somewhat for the respective 

cohort populations as shown in the Figure. Once a service member or Veteran entered a cohort, the service 

treatment record was reviewed to determine if there was 

any documentation of symptomatic CWA exposure and/

or treatment as well as sequelae or subsequent medical 

follow-up. A “positive” finding was a clinical encounter 

record entry for a CWA exposure or any indication of 

a personal CWA or possible personal CWA exposure, 

including the service member or Veteran endorsing or 

mentioning a personal CWA exposure in the absence of 

an AHLTA* clinical encounter record entry for a CWA 

exposure.11 The service member or Veteran may have 

endorsed a history of personal CWA exposure in a follow-up visit, which may or may not have been related to 

a CWA exposure; yet, it is possible that there was not an 

associated initial clinical encounter for CWA exposure 

due to a lack of in-theater electronic health records early 

*AHLTA is the DoD electronic health record system.
78 http://www.cs.amedd.army.mil/amedd_journal.aspx

in the conflict. In this investigation, 

a review of a service member’s or 

Veteran’s AHLTA electronic health 

record is completed and documented in DOEHRS, a Military Health 

System (MHS) resource for entering, 

assessing, managing, and reporting 

occupational and environmental exposures.10,12 Paper treatment records, 

including paper medical records 

from the deployment, were not 

available centrally and were not reviewed as part of this investigation. 

It is recognized that the electronic 

medical record might not contain all 

encounters, particularly those from 

early in the conflict before deployment use of electronic systems was 

in place.

Structured Interview

If the medical record screen contained evidence of a symptomatic 

exposure to a CWA, or for all hotline callers, the service member or 

Veteran was offered a structured 

interview (SI).11 The voluntary SI is 

a tool used to confirm the service 

member’s or Veteran’s inclusion 

based on location, time, and possible exposure to CWA. Based on the 

results of the SI, the service member 

or Veteran may be offered a clinical assessment (CA) at 

a military treatment facility. Service members and Veterans may decline the SI and/or CA without any effect 

on their eligibility for military or Veteran’s benefits.

The SI is a healthcare provider-conducted, telephonic interview that occurs after the medical records screening 

to formally evaluate a potential CWA exposure.9,11 This 

interview does not establish a physician-patient relationship, but serves as a fact-finding effort to determine 

the probability of a confirmed or likely CWA exposure 

based on the service member’s or Veteran’s history of 

exposure, symptoms and the time until onset, and any 

available CWA testing results. A service member or 

Veteran was offered a medical examination if the interviewing provider determined that sufficient evidence existed to support a likely or confirmed CWA exposure. A 

service member or Veteran progressed to the end-point 

determination of “no evidence of symptomatic exposure” if the interviewing provider determined there was 

not a preponderance of evidence to support CWA exposure (eg, the likelihood of CWA exposure for the service 

member or Veteran was determined to be less than 50%). 

Pertinent service member or Veteran information from 

the SI was documented in DOEHRS and uploaded. If 

the interviewing provider determined that the service 

member or Veteran had no evidence of symptomatic 

CWA exposure, the necessary CWA exposure information was documented in DOEHRS. Clinical assessments 

were offered to any service member or Veteran who was 

determined to have a confirmed or likely exposure. Additionally, service members or Veterans who were considered to have no evidence of a symptomatic exposure 

may request and be granted an examination.9

Clinical Assessments

The CAs were conducted at the Walter Reed National 

Military Medical Center (WRNMMC). In order for 

Veterans who were no longer DoD beneficiaries to be 

seen at WRNMMC, Secretarial Designee status was 

obtained. This status allowed invitational travel orders 

to be created for the Veteran to travel to WRNMMC 

and undergo a one-time examination to assess whether 

the Veteran had current signs or symptoms of known 

Chemical Weapons Exposures in Iraq:

Challenges of a Public Health Response a Decade Later

The chemical warfare agent exposure review processes for the respective service 

member and Veteran population cohorts. DOEHRS indicates Defense Occupational 

and Environmental Health Readiness System; STR, service treatment record; PH, 

Purple Heart.

Medical

Records

Review

DOEHRS

& STR

Structured

Interview

Medical

Exam

Examination

Complete Risk

Communication

& Follow up

Personnel File 

Review for PH 

Determination

1

Reported

Cohort

2

Unit

Cohort

3

PDHA/PDHRA

Cohort

Medical

Records

Review

Possible

No

Yes No

DOEHRS

& STR

Structured

Interview

Medical

Exam

Examination

Complete Risk

Communication

& Follow up

Confirmed Exposure

or Health or Well Being

Concerns?

Personnel File 

Review for PH 

Determination

Evidence of

Symptomatic

Exposure?

4

Self Report

Cohort

Medical

Records

Review

No

DOEHRS

& STR

Structured

Interview

Medical

Exam

Examination

Complete Risk

Communication

& Follow up

Yes: Confirmed

Exposure or Health

or Well Being

Concerns

Personnel File 

Review for PH 

Determination

Evidence of

Symptomatic

Exposure?
October – December 2016 79

The Army Medical Department Journal

health effects associated with CWA, including any referrals which the examining provider considered indicated, 

at no cost.11 Lodging and per diem were included. The 

designee status did not include treatment or ongoing follow-up in the MHS. For this effort, APHC(P) provided 

administrative support to schedule SIs and CAs in coordination with WRNMMC, created invitational travel 

orders, and assisted service members and Veterans with 

travel arrangements and vouchers associated with the assessment. The WRNMMC Preventive Medicine Department, through the Occupational Medicine clinic providers, conducted the CAs and coordinated with other specialties as needed, documented the visit in the medical 

record, and provided health risk communication.

Documenting the Investigation

As mentioned earlier, DOEHRS is an MHS resource for 

entering, assessing, managing, and reporting occupational and environmental exposures.12 The Solution Delivery Division of Health Information Technology at the 

Defense Health Agency manages DOEHRS, which consists of multiple business areas: industrial hygiene, environmental health, radiation health, incident reporting, 

and registries. Useful for both garrison and deployed 

operations, it is mandated by various DoD policies and 

public laws and is an exposure system for AHLTA.10,12

The existing incident reporting module was modified to 

meet the needs of the CWA initiative by allowing the 

creation of a record for each individual, attaching the 

medical record, the SI, the CA, and allowing the recording of status and key information throughout the process. This system also contains a mailbox function so 

that records can be forwarded to the appropriate individual when certain steps are completed, allowing traceability throughout the process. In addition, this system 

is a permanent archival system which can be accessed 

by the VA directly or through future DoD-VA information sharing platforms. Although the AHLTA record for 

each individual who undergoes a CA contains the information regarding the visit and the disposition, DOEHRS 

serves as a searchable system to retrieve CWA process 

information on all participants who have entered the 

process, regardless of the disposition, including demographic information, medical record screening results, 

the SI outcome, and the CA outcome.

Recognition

The initial New York Times article1 identified 14 Soldiers 

who, it was claimed, suffered from CWA exposure and 

were not appropriately recognized for their injuries. Information was gathered to determine whether or not these 

individuals were eligible for the Purple Heart award.3

As part of this effort, individuals who were identified 

as having a confirmed or likely exposure to CWA were 

contacted to discuss possible concerns regarding awards. 

Such scenarios included exposure to CWA from the enemy use of an improvised explosive device. Exposure 

through digging up ordnance or contact with old leaking 

munitions is generally not considered to be enemy activity. The Army assisted Soldiers or Veterans who believe 

themselves to possibly be eligible for the Purple Heart 

award to identify and submit the appropriate documentation to support their request for consideration.9

Communication: Keeping the Individual and DoD

Leadership Informed

High-level interest in this process necessitated keeping leadership informed of the recommended approach, 

progress, and roadblocks. In the early phase of the process, daily briefings were conducted between APHC(P) 

and the Office of the Surgeon General to communicate 

changing cohort sizes, progress in identifying and contacting the individuals, as well as the status of draft correspondence to the cohort members, fact sheets, and the 

implementation plan.9

 Although APHC(P) was the lead 

agency on this effort and had the majority of the participants, the other military services also had potential 

exposures. Coordination between representatives from 

their respective Surgeons General and Manpower and 

Reserve Affairs was conducted in weekly briefings to 

Under Secretary Carson. During and between these 

briefings, recommendations and issues were discussed. 

The briefings occurred for months until the overall process, including the CA, was established, although the 

cohorts, particularly Cohort 4, might still grow. The first 

CAs occurred in February 2015, less than 4 months after 

the process was initiated.

Conducting Interviews

The SI was a provider-service member or Veteran conversation designed to gather information from the service member or Veteran about their potential exposure 

to CWA. There were a variety of responses as providers 

spoke to these service members and Veterans. While 

some service members or Veterans were happy that 

the program was in place, some were angry that they 

had been told not to talk about the event, and others 

stated that medical personnel did not always recognize 

the exposure and proceed accordingly. For some, talking about the event and the deployment was traumatic 

and difficult; for others, it was cathartic and a relief to 

get it out in the open. Many expressed the opinion that 

the interview was worthwhile, as well as gratitude that 

“someone cares” and “someone believes them.” It was 

necessary to provide the service member or Veteran 

with the time he/she needed to discuss their exposure 

scenario and concerns in their own way. In some cases, 

individuals had not previously shared this information 
80 http://www.cs.amedd.army.mil/amedd_journal.aspx

with a provider and did not know if they should be concerned about long-term health effects. To successfully 

conduct these interviews, it was essential to practice not 

only good and compassionate listening to establish trust 

and a connection to the service member or Veteran, but 

to allow them to express the variety of their feelings surrounding their exposure experiences.

Long-term Follow-up

A key concern of the author of the initial New York Times

article1 was the lack of medical follow-up for affected 

service members; prior Army policy espoused lifetime 

monitoring. Although it was alleged that these exposures 

were kept “secret” and that medical providers were not 

made aware of the possibility of exposure, in 2004, the 

Army Medical Command (MEDCOM) published and 

widely disseminated guidance documents13,14 prompted 

by 2 chemical agent exposure events. The first incident 

involved 2 service members exposed to a leaking munition containing nerve agent. The second incident involved the exposure of a US Air Force explosive ordnance technician to sulfur mustard in response to dredging a leaking World War I round from the bottom of the 

Atlantic Ocean. Each of these exposures was the subject 

of a medical case report.15,16 The 2004 MEDCOM documents included guidance for the acute medical treatment 

of CWA exposure casualties (with focus on moderate to 

severe exposures), clinical and chain of command notification procedures, and exposure-related evaluation 

and follow-up plan.13,14 Further, the guidance contained 

a broad follow-up protocol, which included surveillance 

of casualties extending beyond full clinical recovery 

due to the relative rarity of casualties suffering symptomatic CWA exposures. In light of casualty interviews 

and inconclusive or nonexistent medical documentation, 

the 26 service members initially identified by The New 

York Times were presumed to have not been clinically 

managed in accordance with the 2004 Army MEDCOM 

guidance for nerve agents and sulfur mustard. It should 

be noted that MEDCOM guidance is not theatre medical 

policy in a combatant command’s area of responsibility, 

and at the time of exposure, the reporting of such casualties was classified and not easily accessible by typical 

MEDCOM queries. Service members with symptomatic 

CWA exposure in theatre may have been treated appropriately and followed-up on redeployment, but no centralized documentation was available.

The APHC(P) collaborated with representatives from 

the Army, Navy, Marine Corps, Air Force, Defense 

Health Agency, and VA, as well as academic experts and 

other nongovernmental personnel to review the scientific basis for the recommended long-term management 

of CWA casualties. The collaborative team specifically 

focused efforts on sarin and sulfur mustard by incorporating a review of published literature, best clinical 

practices, and information gleaned from exposure-based 

interviews and clinical examinations of CWA casualties. 

The literature review of military, medical, and scientific 

articles was conducted to research information and focused on information about the persistent health effects 

and the delayed-onset of signs and symptoms following 

exposure to chemical agents.17-23 The review identified 

articles describing the use of CWAs during World War 

I, where the types of weapons employed ranged from 

tear gas and mustard gas to phosgene and chlorine. Also 

found during the review was the act of domestic terrorism perpetrated by members of Aum Shinrikyo in Matsumoto, Japan, who released sarin gas from several sites 

in the Kaichi Heights area during the evening of June 

27 and morning of June 28, 1994. This event, known as 

the Matsumoto incident, resulted in the deaths of 8 people and injuries to over 200 others. It occurred about 9 

months before the better known Subway Sarin Attack on 

March 20, 1995, an act of domestic terrorism perpetrated 

in Tokyo, Japan, by members of the same religious group 

who released sarin gas simultaneously from 5 containers 

on 3 different Tokyo subway lines. Information was also 

available relating to exposures during the Iran-Iraq War 

in which Iraq used large quantities of chemical weapons, 

reportedly mostly sarin and sulfur mustard, against both 

civilian and military populations in Iran.

The focus on the long-term medical management presupposed that the service member or Veteran underwent 

a clinical evaluation which determined that all acute 

and subacute health effects of the CWA exposure had 

resolved. The review report does not address those 

with high-level exposures, as these individuals often 

have life-long health issues and may need to remain 

under the care of specialists throughout their lives. To 

our knowledge, none of the exposures associated with 

the investigation fit that description. While the report 

presents some background and information about longterm health effects, its main purpose is to provide guidance on long-term follow-up of exposed individuals. 

Specific follow-up recommendations resulting from 

clinical evaluations should be discussed with the individual using principles of shared decision-making and 

should be documented in his/her medical record. All 

individuals who undergo evaluation for symptomatic 

CWA exposure(s) should be provided with educational 

materials. For this initiative, due to limitations in the 

ability to predict long-term health outcomes, individuals with confirmed symptomatic exposure(s) to CWAs 

will be sent a follow-up letter or health status questionnaire from APHC(P) on a periodic basis. The purpose of 

this periodic contact is threefold: (1) to provide patient 

Chemical Weapons Exposures in Iraq:

Challenges of a Public Health Response a Decade Later
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The Army Medical Department Journal

education and updates when new information becomes 

available; (2) to help ensure optimal treatment of identified health conditions; and (3) to reassure the patient 

and demonstrate continued commitment. The DoD will 

communicate with the VA as needed.

Follow-up for Mustard Exposures

All individuals with ocular exposure to sulfur mustard 

should be educated about the importance of good eye 

hygiene and eye care (eg, avoiding putting anything in 

the eyes that was not designed specifically for that use, 

seeing an eye care professional regularly). If an individual required eight weeks or more of medical care at the 

time of exposure, they should also be educated about 

the possibility of recurrent keratopathy and should be 

encouraged to see an eye care professional immediately 

for any unexplained eye pain or visual changes.

All individuals with ocular exposure to sulfur mustard 

should be counseled to notify their eye care professional 

and other healthcare providers about their exposure history. Late-onset or late-occurring ocular effects (these 

are effects which were not present acutely or subacutely after the exposure) of sulfur mustard exposure are 

impossible to predict and are unlikely to be identified 

in a periodic evaluation. Fortunately, late-onset ocular effects are unlikely to occur based on the currently known level of exposure to US military personnel; 

therefore, no formal DoD or VA medical surveillance is 

recommended.

Individuals exposed to sulfur mustard by inhalation 

should be educated about the possibility of long-term 

pulmonary effects and the importance of avoiding pulmonary toxins, including tobacco smoke, second-hand 

smoke, etc. These individuals should be educated about 

the importance of establishing and maintaining a close 

ongoing relationship with a primary care provider, so 

that changes in their clinical status are more likely to 

be detected. All individuals with symptomatic inhalation exposure to sulfur mustard should be encouraged to 

report all cases of pulmonary symptoms and/or pulmonary diagnoses to their provider. Each encounter for pulmonary evaluation should be used as an opportunity to 

emphasize the importance of avoiding pulmonary toxins—most notably, tobacco smoke. Fortunately, there 

have been no documented cases of high-level exposures 

to sulfur mustard involving US service members in a 

combat zone since World War II.

All individuals with symptomatic dermal exposure to 

sulfur mustard should be educated about the possibility of long-term dermal effects and the importance of 

avoiding dermal injuries, including sun- and tanning 

booth-induced injuries to the affected skin. Individuals 

with symptomatic dermal exposure to sulfur mustard 

with residual scarring at the site(s) of exposure-related 

dermal burns should be educated about the possibility 

of cicatricial malignancies and the importance of seeing 

a skin care professional if the scar(s) begin(s) to change 

color, shape, texture, etc. All individuals with asymptomatic dermal exposure to sulfur mustard should be 

reassured regarding the absence of evidence of longterm effects in the absence of acute effects. They should 

also be educated about the importance of avoiding dermal trauma, including sun exposure and tanning booth 

injuries.

There is no clear scientific or medical evidence concerning any risk of late-onset skin effects. If such effects 

exist, they are likely to be uncommon. They are also 

unlikely to be identified in a regular periodic evaluation; 

therefore, no formal DoD or VA medical surveillance is 

recommended.

Based on the levels of exposure during exposure incidents involving US service members while deployed to 

combat zones since WWII, systemic effects of sulfur 

mustard exposures are unlikely to occur. Therefore, no 

formal DoD or VA medical surveillance is recommended.

Follow-up of Nerve Agent Exposure

Signs and symptoms of nerve agent exposure can range 

from frank effects of cholinergic poisoning with highlevel exposure (convulsions, near lethality, or requiring 

intervention to prevent death), to the presence of threshold cholinergic effects (miosis, rhinorrhea, measurable 

depression of cholinesterase) with intermediate exposures, to an absence of immediate clinical signs and 

symptoms with minimal exposure. If the eyes are exposed to vapor only, miosis may be the only sign. Currently, the literature does not support the development 

of late-onset symptoms in a nerve agent-exposed person after the acute effects of nerve agent exposure have 

resolved.

Although there have been no documented cases of highlevel exposures to nerve agents involving US service 

members since development of these agents in the 1930s, 

individuals with high-level exposure to nerve agents 

should undergo comprehensive neurological evaluation 

(with consideration of neuropsychological, vestibular, 

and ophthalmologic testing and/or referrals) to determine if there are any residual effects from their exposures. This also applies to highly exposed individuals 

who are asymptomatic from the abnormalities identified 

at the time of their initial referral for specialty evaluation. This/these evaluation(s) should attempt to isolate 
82 http://www.cs.amedd.army.mil/amedd_journal.aspx

any residual nerve agent exposure effect from effects 

due to posttraumatic stress disorder (PTSD) and/or traumatic brain injury (TBI), which can be difficult. If this 

evaluation and concurrent testing are normal, or, if abnormal, explained by other factors such as PTSD or TBI, 

no further follow-up is recommended. If the above tests 

are abnormal and cannot be explained by a non-nerve 

agent-related condition or situation, it is recommended 

that the individual be referred to a neurologist, neuropsychologist, otolaryngologist, or ophthalmologist for 

further evaluation and follow-up as appropriate. Once 

these tests normalize, another cause for the abnormalities is identified, or the individual becomes asymptomatic with residual test abnormalities, no further followup is recommended.

All individuals with intermediate-level exposure to 

nerve agents (documented exposure that required treatment at the time) should undergo comprehensive neurologic evaluation (with consideration of neuropsychological and vestibular testing) to determine if there are 

any residual effects from their exposures. This applies 

whether or not they are symptomatic at the time of their 

initial referral for specialty evaluation. This evaluation 

should attempt to isolate any residual nerve agent exposure effects from effects due to PTSD and/or TBI. If 

this evaluation and concurrent testing are normal, or, if 

abnormal, explained by other factors, no further followup is recommended. If the above tests are abnormal and 

cannot be explained by a non-nerve agent-related condition or situation, it is recommended that the individual 

be referred to a neurologist, neuropsychologist, or otolaryngologist for further evaluation and follow-up as 

appropriate. Once these tests normalize, another cause 

for the abnormalities is identified, or the individual becomes asymptomatic with residual test abnormalities, 

no further follow-up is recommended.

All individuals with mild or low-level exposure to nerve 

agents should be educated regarding what is known 

about late-onset effects of nerve agent exposure, especially in cases of mild or no symptoms at the time of the 

exposure. Individuals with a history of possible exposure to nerve agent vapor only (with no possibility of 

liquid exposure) who had no signs of exposure within 15 

minutes of the potential exposure can be considered nonexposed (because these effects occur within seconds to 

minutes after exposure). No follow-up is recommended.

Conclusion

Since the onset of the public health investigation in October 2014 until the time of this writing (March 2015), 

over 7,504 service members and Veterans have been 

evaluated in this process. Cohort 1 ultimately contained 

48, while Cohort 2 had 226, and 5,777 were identified 

via the PDHA forms plus an additional 103 identified in 

operational records brought Cohort 3 to a total of 5,880. 

There were 1,350 hotline callers comprising Cohort 4. A 

total of 7,474 medical record reviews were completed, 

and 1,152 SIs conducted. At the end of the process, 6,439 

individuals were identified as having no evidence of a 

symptomatic exposure. Two hundred sixty-six individuals were categorized as confirmed or likely to have had 

a symptomatic exposure. Of these, 111 have completed 

the CA and 52 have declined it. An additional 52 individuals had no evidence of symptomatic exposure but 

requested an examination anyway. At the onset of the 

effort in October 2014, APHC(P) worked to identify the 

individuals in Cohort 1 and called them to discuss their 

exposures, signs, and symptoms at the time; the medical care that they had received; and their current health 

status. A decision was made that all members of Cohort 

1 would be seen at WRNMMC. While this strategy incurred travel costs, the purpose of having all individuals 

evaluated at one location was to promote standardization. A previous surveillance program established for 

individuals who were exposed to a hazard at the Qarmat 

Ali Water Treatment Plant in Iraq23 employed a limited 

number of medical treatment facilities to conduct the 

evaluations. This was to ensure the needed level of specialty care was available, and to limit providers to a few 

who understood the objectives of the examination and 

were comfortable with the risk communication aspects 

of the program. This had been successful and was the 

model of choice for the effort. The CA was designed 

after a review of the literature regarding acute as well as 

chronic exposures, but it was designed without knowledge of the actual level of exposure of those who would 

be evaluated.

As described earlier, the 4 goals of the process were to:

1. identify, contact, and evaluate service members 

and Veterans for potential CWA exposure;

2. offer and provide service members and Veterans 

with likely or confirmed CWA exposure a medical 

exam, if appropriate;

3. document these efforts in DOEHRS and individual service treatment records and ensure the VA is 

informed of these findings; and

4. consider appropriate recognition for service members and Veterans with injuries resulting from 

likely or confirmed CWA exposure (these were 

met (to date)).

Coordination with the VA to provide identifying information on participants has already occurred. A tremendous amount of effort was expended to process the 7,504 

Chemical Weapons Exposures in Iraq:

Challenges of a Public Health Response a Decade Later
October – December 2016 83

The Army Medical Department Journal

potentially exposed individuals to date, and the ratio of 

confirmed or likely to potentially exposed was small at 

226/7,504, or 3.5%. In almost every case, the service 

member or Veteran had a usual source of care, and many 

of them were already being followed, for example, for 

their respiratory complaints. The assessment conducted 

was not a compensation examination for the VA, but 

served to document an exposure (although most often 

with no true measure of dose). In the future, should an 

individual develop a condition that they attribute to their 

past exposure, in the absence of a presumption, another 

examining physician will assess the probability of an 

association. These efforts to identify service members 

and Veterans who had likely or confirmed exposures to 

CWA while in theatre might have been avoided if there 

was a central registry of service members who had been 

determined through medical channels to have had such 

an exposure. This serves to illustrate the importance of 

field recognition, care, and reporting of symptomatic 

exposures, and of making this information available in 

an unclassified format. In most instances when signs 

and symptoms were typical, contact with the medical 

community ultimately occurred and these exposures 

were known outside of classified channels.15,16 At present, DOEHRS has an incident-reporting module for this 

purpose. While some individuals may not have sought 

medical care, had there been a centralized, unclassified 

location to report these exposures, or had the postdeployment health assessments clearly identified them, it would 

have been possible to conduct active or passive surveillance. The question on the PDHA that addresses chemical exposures is rolled in with other exposures, making 

it difficult to search the forms for likely exposures. To 

the degree that reporting remains classified, there remain 

substantial barriers to identifying and following such exposures. Ideally, after being promptly recognized and 

treated in the field with concurrent electronic medical 

record documentation, personnel symptomatically exposed to CWA would redeploy and receive appropriate 

follow-up care from their next healthcare provider. Even 

then, however, there would be no ability to easily identify 

these individuals, should the need arise, apart from the 

use of a very specific reporting code. To prevent future 

difficulties, unique symptomatic exposures should be reported through unclassified channels in accordance with 

deployment policy and tracked when appropriate.10

References

1. Chivers CJ. The secret casualties of Iraq’s abandoned chemical weapons. New York Times [archives]. October 14, 2014. Available at: http://www.

nytimes.com/interactive/2014/10/14/world/mid

dleeast/us-casualties-of-iraq-chemical-weapons.

html. Accessed July 6, 2016.

2. Chivers CJ. Army apologizes for handling of 

chemical weapon exposure cases. New York Times

[archives]. March 25, 2015. Available at: http://

www.nytimes.com/2015/03/26/world/middleeast/

army-apologizes-for-handling-of-chemical-weap

on-exposure-cases.html. Accessed July 6, 2016.

3. Department of Defense Manual 1328.33: Manual 

of Military Decorations and Awards: DoD-Wide 

Performance and Valor Awards; Foreign Awards; 

Military Awards to Foreign Personnel and U.S. 

Public Health Service Officers; and Miscellaneous 

Information. Washington, DC: US Department of 

Defense; November 23, 2010 [change 2, March 13, 

2015]. Available at: http://www.dtic.mil/whs/direc

tives/corres/pdf/134833vol3.pdf. Accessed July 7, 

2016.

4. Under Secretary of the Army. Memorandum to 

US Secretary of Defense: Iraqi Chemical Weapon 

Exposure. Washington DC: US Department of the 

Army; 10 November 10, 2014.

5. Chemical Weapons Convention Implementation 

Act of 1998, Pub L No. 115-277, div I, 112 Stat 2681-

2856. Available at: http://www.cwc.gov/cwc_au

thority_legislation_s3.html. Accessed July 7, 2016.

6. Sidell FR, Takafuji ET, Franz DR, eds. Medical 

Aspects of Chemical and Biological Warfare. Fort 

Sam Houston, TX: Borden Institute; 1997.

7. Agency for Toxic Substances and Disease Registry. Medical Management Guidelines for Blister 

Agents such as Sulfur Mustard Agent H or HD 

(C4H8Cl2S), Sulfur Mustard Agent HT. CDC Website. October 21, 2014. Available at: https://www.

atsdr.cdc.gov/mmg/mmg.asp?id=942&tid=191. Accessed July 7, 2016.

8. Centers for Disease Control and Prevention. Emergency Preparedness and Response: Facts About 

Sulfur Mustard [internet]. CDC Website. May 2, 

2013. Available at: http://emergency.cdc.gov/agent/

sulfurmustard/basics/facts.asp. Accessed July 7, 

2016.

9. Under Secretary of the Army. Memorandum: Iraq 

CWA Exposure Review Implementation Guidance. 

Washington DC: US Department of the Army; 

March 20, 2015.

10. Department of Defense Instruction 6490.03, Deployment Health. Washington, DC: US Department of Defense; August 11, 2006 [updated September 30, 2011]. Available at: http://www.dtic.mil/

whs/directives/corres/pdf/649003p.pdf. Accessed 

July 7, 2016.

11. US Army Public Health Center (Provisional). Technical Guidance for the Iraq Chemical Weapon Exposure Review. 2015. Internal military document 

not readily accessible by the general public.

12. Department of Defense Instruction 6055.05. Occupational and Environmental Health (OEH). Washington, DC: US Department of Defense; November 11, 2008. Available at: http://www.dtic.mil/

whs/directives/corres/pdf/605505p.pdf. Accessed 

July 7, 2016.
84 http://www.cs.amedd.army.mil/amedd_journal.aspx

13. Office of the Army Surgeon General. Memorandum: Medical Evaluation, Follow-up and Recording of Chemical Warfare (CW) Nerve Agent Casualties Outside of Storage, Demilitarization and 

Research Settings. Washington, DC: US Army 

Medical Department; September 10, 2004.

14. US Army Medical Command. Memorandum: 

Medical Management, Evaluation, Follow-up, and 

Recording of Chemical Warfare (CW) Mustard 

Agent Casualties Outside of Storage, Demilitarization and Research Settings. Washington, DC: US 

Army Medical Department; October 28, 2004.

15. Loh Y, Swanberg MM, Ingram MV, Newmark J. 

Case study: long term cognitive sequelae of sarin 

exposure. Neurotoxicology. 2010;31(2):244-246. 

Available at: http://www.sciencedirect.com/sci

ence/article/pii/S0161813X09002769. Accessed 

July 8, 2016.

16. Newmark J, Langer J, Capacio B, Barr J, McIntosh RG. Liquid sulfur mustard exposure. 

Mil Med. 2007;172(2):196-198. Available at: 

http://publications.amsus.org/doi/pdf/10.7205/

MILMED.172.2.196. Accessed July 8, 2016.

17. Mann I. A study of eighty-four cases of delayed 

mustard gas keratitis fitted with contact lenses. Br 

J Ophthalmol. 1944;28(9):441-447.

18. Balali-Mood M, Hefazi M, Mahmoudi M, Jaafari 

MR. Long-term complications of sulfur mustard 

poisoning in severely intoxicated Iranian veterans. Fundam Clin Pharmacol. 2005;5(9):1479-1485. 

Available at: https://www.researchgate.net/publica

tion/7456308_Long-term_complications_of_sul

fur_mustard_poisoning_in_severely_intoxicated_

Iranian_veterans. Accessed July 8, 2016.

19. Ghanei M, Fathi H, Mohammad MM, Aslani J, 

Nematizadeh F. Long-term respiratory disorders 

of claimers with subclinical exposure to chemical 

warfare agents. Inhal Toxicol. 2004;16(8):491-495.

20. Murata K, Araki S, Yokoyama K, Okumura T, Ishimatsu S, Takasu N, White RF. Asymptomatic sequelae to acute sarin poisoning in the central and 

autonomic nervous system 6 months after the Tokyo subway attack. J Neurol. 1997;244(10):601-606.

21. Miyaki K, Nishiwaki Y, Maekawa K, et al. Effects 

of sarin on the nervous system of subway workers 

seven years after the Tokyo subway sarin attack. J 

Occup Health. 2005;47(4):299-304.

22. Yamasue H, Abe O, Kasai K, et al. Human brain 

structural change related to acute single exposure 

to sarin. Ann Neurol. 2007;61(1):37-46.

23. Weese CB. Evaluation of exposure incident at the 

Qarmat Ali water treatment plant. US Army Med Dep 

J. April-June 2009:10-13. Available at http://www.

cs.amedd.army.mil/AMEDDJournal/2009aprjun.

pdf. Accessed July 7, 2016.

Authors

Dr Baird is Chief, Environmental Medicine Division, US 

Army Public Health Center, Aberdeen Proving Ground, 

Maryland.

MAJ Mirza is the Occupational Medicine Division 

Chief, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Ms Sharkey is an Epidemiologist, Environmental Medicine Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

Dr Teichman is a Physician, Environmental Medicine 

Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

MAJ Longmire is a Physician, Environmental Medicine 

Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

Dr Harkins is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

LTC Llanos is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, Maryland.

Dr Abraham is an Epidemiologist, Environmental Medicine Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

Dr McCannon is a Physician, Environmental Medicine 

Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

Dr Tinklepaugh is a Physician, Environmental Medicine Division, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

Dr Heller is a Health Risk Assessor, Environmental 

Medicine Division, US Army Public Health Center, Aberdeen Proving Ground, High-level

COL Rice is Portfolio Director and Consultant to The 

Surgeon General for Occupational and Environmental 

Medicine, US Army Public Health Center, Aberdeen 

Proving Ground, Maryland.

Chemical Weapons Exposures in Iraq:

Challenges of a Public Health Response a Decade Later
October – December 2016 85

Waste-to-energy (WTE) offers a partial solution at the 

convergence of 2 major Department of Defense (DoD) 

concerns: (1) addressing health effects due to burn pit 

emissions exposures and (2) reducing dependency on 

fossil fuels in contingency environments. Operating 

forces, combatant commands, and technology developers are excited about the prospect of using WTE as a solution, but a multitude of considerations and limitations 

must be integrated before it can be declared a success. 

Waste-to-energy systems may produce cost benefits and 

reduced environmental impact, but ancillary advantages 

such as a reduction in health related concerns can only 

be inferred from minimally available information and 

data. Accurate problem framing is the first, crucial step 

to developing successful military equipment that can 

be employed in austere conditions where US forces are 

deployed. To date, industry has been very successful in 

developing large scale WTE systems intended to handle 

municipal solid waste from civilian urban areas. However, such commercially available systems are not designed for harsh mobile deployment applications where 

burn pits have commonly been the expedient solution 

to solid waste disposal. The continuous presence of US 

forces in austere, deployed environments over the last 

decade has produced a growing concern over adverse 

health effects to service members from toxic burn pit 

emissions. These concerns have pushed alternate technologies, such as WTE, into the collective spotlight.

When operating far distances from established installations, the DoD employs base camps which vary in 

physical size and personnel in order to accomplish various missions. The exact base camp categories will be 

explained in more detail later, but generally the camps 

are categorized as “extra small,” “small,” “medium,” 

and “large.” Understanding the typical military waste 

streams at extra small and small base camps provides 

an awareness of the baseline of materials that require 

waste management treatment. This article synthesizes 

these components to create an understanding for the 

dynamic considerations that must be addressed to develop systems that could potentially create a more efficient, sustainable, and ultimately safer environment for 

US service members.

Understanding the current state of knowledge for burn 

pit risk is the first step in analyzing what emissions hazards from burning waste must be addressed by a WTE 

system. Knowledge gaps from limited burn pit emission 

sampling data in deployed environments have been partially addressed through simulated emissions testing.

Presented in this article are the required DoD critical 

performance parameters and characteristics for a WTE 

system that is a safe alternative to burn pits. Within environmental considerations, this analysis is primarily 

focused on managing nonhazardous solid waste, defined 

as “any material or substance [solid or liquid] that is inherently waste-like by being no longer suitable for its 

originally intended purpose” 1

 In addition to narrowing 

the scope of environmental considerations to solid waste 

management practices, considerations will also be limited to bases with fewer than 2,000 personnel (of which 

extra small and small base camps are considered).2

Human Health Risk from Open-Air Burn Pits

Concern over the health effects of burning solid waste 

during deployments in combat theaters has been voiced 

by service members, veterans, the media, Congress, and 

the President. It has been the subject of several joint DoD 

and Veterans Administration (VA) symposia, scholarly 

articles, a military medical textbook, congressional inquiries, and federal legislation.3-9

Waste disposal in contingency settings requires thoughtful consideration of waste stream segregation, safe 

disposal of hazardous materials, personnel safety, and 

the available disposal infrastructure, in addition to the 

technology to support incineration and landfills for other disposal options. During Operations Iraqi Freedom 

Bridging the Gap Between Burn Pits and

 Waste-to-Energy Technology: Safe and

 Effective Waste Management in

 Contingency Operations

Capt Matthew T. Barnes, USMC Capt John A. Crutchfield, USMC

Coleen P. Baird, MD, MPH Kawakahi Amina

Capt Anthony D. Suh, USMC Lt Col Robert M. Eninger, USAF
86 http://www.cs.amedd.army.mil/amedd_journal.aspx

(OIF) and Enduring Freedom (OEF), there was a notable absence of supporting infrastructure or contracting 

possibilities for field waste disposal. The only limited 

methods of field disposal were burial, incineration, or a 

combination of the two. At times, the sheer volume of 

waste required near continuous operation of burn pits 

at several locations, resulting in the constant production of smoke. When conducting an open burn of solid 

waste, siting of the burn area is critical to ensure that it 

is downwind from living quarters and camp populations. 

Burn pit smoke plume direction is dependent on weather 

conditions, and smoke can linger low to the ground during inversions.10 Consequently, considerations such as 

the direction of prevailing winds and location of personnel billeting areas had to be continually assessed as use 

of open burning persisted.

As clearly illustrated in Figure 1, thick black smoke from 

open pit burning was often a visual cue accompanying 

odors, eye irritation, and/or cough. As the size and number of inhabitants increased at Joint Base Balad, Iraq, 

trash volume grew from 2 tons per day to several hundred. While incinerators were purchased relatively early 

in the base expansion of this specific example, contractual issues delayed their use, and in response, concerned 

preventive medicine personal conducted air sampling 

from January to April 2007. The sampling targeted expected burn pit emissions, including particulate matter (PM), volatile organics, metals, polycyclic aromatic 

hydrocarbons (PAH), and polychlorodibenzodioxins/

furans. The sampling was conducted over multiple 24-

hour periods at locations chosen to represent typical and 

maximum exposure levels for the general population. 

Additional sampling was conducted during different seasons. From the 163 samples collected, 4,811 individual 

analyte results were obtained and used in a quantitative 

screening human health risk assessment. The cancer risk 

estimated in this assessment was in the range considered 

to be “acceptable” under US Environmental Protection 

Agency (EPA) guidelines, but some volatile organic compounds were measured at levels that might be associated 

with acute irritation.10,11 Limitations of the environmental sampling and risk assessment methodology include 

incomplete capture of the variability in waste streams 

and meteorological conditions over time, and the potential presence of toxicants that were not quantified.5

Dramatic photographs of burn pit smoke and accounts 

of the exact nature of items (plastic water bottles, soiled 

military uniforms, tires, etc) which had been burned 

(indicating indiscriminant burning) circulated on social media and generated further concern. Congress responded with language included in the National Defense 

Authorization Act for FY 2010 which identified items 

that were prohibited from uncontrolled burning, and 

limited the time period that a base commander could 

rely on open burning as the waste disposal method at 

base camps housing more than 100 personnel.12 In 2011, 

the Institute of Medicine (IOM) assessed air sampling 

data, risk assessment information, and relevant epidemiological data and concluded that there was insufficient 

evidence to draw firm conclusions regarding long-term 

health risks associated with burn pit exposure.7

 The IOM 

committee noted that monitoring data “omitted some 

of the pollutants considered criteria pollutants in the 

United States such as sulfur dioxide, ozone, nitrogen dioxide, ozone, nitrogen dioxide, and carbon monoxide.” 

They also stated that it was likely that additional pollutants were present as “the burning of household waste 

is known to emit other pollutants,” but were simply not 

measured due to time or budget constraints. The IOM 

determined that health effects (particularly respiratory) 

from burn pit emissions exposures are plausible, due primarily to PM, but that burn pits were likely only one of 

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations

Figure 1. Smoke from open air burn pits, Joint Base Balad, Iraq, in 2006. Photo courtesy of CPT Scott Newkirk, USA.
October – December 2016 87

The Army Medical Department Journal

many sources contributing to ambient PM levels. The literature reviewed during the study provided limited but 

suggestive evidence of decreased pulmonary function 

(but not disease) associated with combustion products.

Continued, active stakeholder engagement with Congress resulted in the Dignified Burial and Other Veterans’ 

Benefits Improvements Act of 2012 which was signed 

into law on January 10, 2013.4

 The law required the VA 

to establish a voluntary registry for veterans who had 

deployed to locations near open burn pits. The registry 

was subsequently expanded to include all deploymentrelated airborne hazards (to address hazard sources beyond burn pits) and named the database the “Airborne 

Hazards and Open Burn Pit Registry” (AHOBPR). In 

August 2013, DoD committed to include active duty service members in the AHOBPR. Open burning of trash 

may be only one of many contributors to service members’ health risk, but it has been viewed by many as a 

risk fully under DoD control and thus unacceptable as 

a continued standard operating procedure. To date, over 

59,000 service members and Veterans have enrolled in 

the AHOBPR registry, and the IOM is reviewing the information in order to determine how to best utilize the 

self-reported data.

Respiratory conditions are the most plausible and most 

studied consequence of exposure to burn pit emissions. 

Geographically, personnel deployed to Southwest Asia 

are also exposed to other respiratory hazards, including 

fine dust, emissions from vehicles, generators, weaponry, and local industry. The DoD conducted environmental sampling to characterize these exposures, focusing on ambient PM, a hazard which routinely exceeds 

health guidelines in the region.13,14 The studies evaluating associations between deployment and respiratory 

health indicate a range of different and occasionally 

contradictory findings, including: (a) no evidence of an 

association between deployment and chronic respiratory conditions 15,16; (b) an association between specific 

respiratory diseases and deployment 6,17,18; and (c) evidence of increased respiratory symptoms but not a specific diagnosed disease.19-22 Although these studies have 

methodological limitations that constrain the strength of 

the conclusions that can reasonably be drawn from them, 

their findings warrant continued investigation.

Despite the interest in the health effects of burn pits, 

there have been few studies to specifically address health 

outcomes associated with them rather than those involving deployment as a variable. Newly reported chronic 

bronchitis or emphysema, newly reported asthma, and 

self-reported respiratory symptoms and possible burn 

pit exposure were examined among deployed Army and 

Air Force personnel surveyed in 2004-2006 and 2007-

2008 (N=22,844). Increased symptom reporting was 

observed among Air Force personnel located within 2 

miles of Joint Base Balad; however, this finding was 

marginally statistically significant. This study did not 

generally support an elevated risk for respiratory outcomes other than symptoms among personnel deployed 

within proximity of documented burn pits in Iraq.9

 Another retrospective cohort study was conducted among 

military personnel who, between January 2005 and June 

2007, were deployed to either of 2 locations with burn 

pits in Iraq, or to either of 2 locations without burn pits 

in Kuwait.6

 Incidence rate ratios (IRRs) were estimated 

using 2 nondeployed reference groups. Rates among 

personnel deployed to burn pit locations were also compared directly to those among personnel deployed to 

locations without burn pits. Significantly elevated rates 

of encounters for respiratory symptoms (IRR=1.25; 

95% CI: 1.20-1.30) and asthma (IRR = 1.54; 95% CI: 

1.33-1.78) were observed among the formerly deployed 

personnel relative to personnel stationed in the United 

States. Personnel deployed to burn pit locations did not 

have significantly elevated rates for any of the outcomes 

relative to personnel deployed to locations without burn 

pits. These results are consistent with the hypothesis that 

OIF deployment is associated with subsequent risk of respiratory conditions. Elevated medical encounter rates 

were not uniquely associated with burn pits.

The IOM review of data on the burn pit registrants may 

stimulate research into other potentially related health 

outcomes, such as cancer, for example. If specific associations develop, it is a possibility that specific health 

outcomes could be presumptively linked to burn pits by 

the VA. Whether associations with health conditions 

emerge or not, continued open burning of large volumes 

of trash is perceived to be dangerous to service members’ health, unnecessarily consume political goodwill 

with the host country, and are an unacceptable risk from 

a force protection standpoint.

Simulating Emissions from Open-Air Burn Pits

Operational burn pits, such as those used at large scales 

during OIF and OEF, no longer exist for study. Therefore, simulating open air burn pit emissions is a critical 

tool to fill knowledge gaps for health and environmental 

effects. The challenge of simulated testing is twofold. 

First, the simulated waste must be reasonably representative of waste compositions observed across the range 

of waste characterization studies and waste input methods and composition should be uniform across various 

tests. Secondly, the emissions data collection methods 

should be uniform across tests, which allows for comparative analysis.
88 http://www.cs.amedd.army.mil/amedd_journal.aspx

In 2012, two studies related to emissions from “militarywaste” sought to gain better understandings of open pit 

burning in an appreciably controlled environment. The 

emissions analyses of both studies were comprehensive 

and both efforts researched similar emissions constituents for various burn conditions. One study analyzed 

simulated military waste at the EPA’s Open Burn Test 

Facility (OBTF) to determine the effect on emissions 

when plastics were removed from the waste stream, 

namely plastic water bottles.23 The emissions analysis 

included: polycyclic aromatic hydrocarbons (PAHs), 

volatile organic compounds (VOCs), particulate matter 

(PM10, PM2.5), polychlorinated and polybrominated dioxins/furans (PCDD/F and PBDD/F), and criteria pollutants. The study concluded that targeted removal of 

plastics (such as water bottles) “has no apparent effect 

on reducing pollutants and may even result in increased 

production of PCDD/Fs and PBDD/Fs pollutants” due to 

reduced British thermal unit (BTU) content of the waste 

resulting in lower overall combustion temperatures.23

The second study compared emissions from 2 separate 

waste streams (municipal solid waste and US Army 

Depot waste) by way of 2 different disposal techniques 

(burn pits and an air curtain burner). The article studied, 

“a comprehensive array of emissions... including CO2, 

PM2.5, volatile organic compounds (VOCs), polyaromatic hydrocarbons (PAHs), polychlorinated dibenzodioxins and -furans (PCDDs/PCDFs), polybrominated 

dibenzodioxins and -furans (PBDDs/PBDFs), and metals.” 24 The results suggested that emissions from the 

air curtain burner were significantly lower for PM2.5, 

VOCs, and PAH, and 50 times lower for PCDD/PCDF 

and PBDD/PBDF as compared to the open pit burning.24

While this study was very informative, both disposal 

methods employed actual municipal solid waste and 

garrison waste with unknown variations of composition 

and consistency. A standardized waste stream that simulates military waste compositions would be beneficial 

for similar tests in the future. Moreover, a deliberately 

constructed and precisely controlled military waste 

standard would reduce uncertainty associated with varied waste streams and allow for more accurate comparison between studies.

Open Burning Emissions of Interest

Common emissions of interests from burning waste 

can be drawn from the 2 studies mentioned above 23,24

and generally include PM, VOCs, PAHs, and PCDDs/

PCDFs. However, to meet regulatory standards, a 

shorter bare-minimum emission testing list is available. 

Nonetheless, to meet academic research objectives, a 

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations

Figure 2. Comprehensive emissions constituent list. Data from Woodall et al,23 Aurell et al,24 and EPA.25

Comprehensive Constituent List

40-CFR Table 1

(OSWI)

Dioxins/Furans PXDD/PXDF

PM2.5 and PM10

Carbon Monoxide (CO)

Sulfur Dioxide (SO2)

Nitrogen Oxides (NOX)

(3/17) Metals

Cadmium (Cd)

Lead (Pb)

Mercury (Hg)

Opacity

(1/5) Halogens

Hydrogen Chloride (HCl)

Health Research

Volatile Organic Compounds (VOCs)

Semi-Volatile Organic Compounds (SVOCs)

Carbon Dioxide (CO2)

Oxygen (O2)

(16/21) PAHs

(5/17) Metals

Arsenic (As)

Chromium (Cr)

Copper (Cu)

Iron (Fe)

Nickel (Ni)

(4/5) Halogens

Total Hydrocarbons (THCs)

Polychlorinated Biphenyls (PCBs)

(5/21) PAHs

Hexavalent Chromium

(9/17) Metals

Antimony (Sb) Barium (Ba) Beryllium (Be)

Cobalt (Co) Manganese (Mn) Phosphorus (MP)

Selenium (Se) Silver (Ag) Thallium (Ti)

Zinc (Zn)
October – December 2016 89

The Army Medical Department Journal

much longer list of testing is possible. Several factors 

and regulations must be considered to determine what 

emissions are critically important for analysis. The size 

and function of a system for waste management application at extra small and small base camps would classify 

the system as an other solid waste incineration (OSWI) 

unit under 40 CFR §6025 for systems built after 2004. 

Table 1 to Subpart EEEE of 40 CFR §60 specifies 10 air 

pollutant concentration limitations for OSWI systems, 

presented in Figure 2. While relying on the regulations 

outlined in 40 CFR is appropriate for environmental 

regulations, it does little to inform researchers about the 

more than 180 emissions (http://www.epa.gov/haps/ini

tial-list-hazardous-air-pollutants-modifications) that are 

hazardous air pollutants and are toxic to human health. 

The US Army Research Laboratory provides an extensive list of possible emissions that can be tested according to EPA methods.26 Previous tests on simulated burn 

pit emissions that focused on health and environmental 

factors produced a list between the extremes of minimal 

requirements to comply with regulations and a comprehensive list that could be achieved with an unlimited 

budget (Figure 2).

Emissions considerations must incorporate civilian regulations established by the EPA, such as the National 

Ambient Air Quality Standards (https://www.epa.gov/

criteria-air-pollutants/naaqs-table) and the Clean Air 

Act (42 USC §7401 et seq (1970)), for the system to be 

permitted for use in the guidelines established as Military Exposure Guidelines.27 Additionally, the Overseas 

Environmental Baseline Guidance Document 28 is applicable for planning WTE use in a deployed contingency 

environment. The body of knowledge for emissions is 

well-researched, and specific studies for health and environmental concerns for individual and varied emissions classes are available.

Emissions analysis during WTE technology development and assessment will generally be restricted due 

to limited money and/or time. Testing comprehensive 

lists of emissions requires significant resources, involving a multitude of sampling trains, elaborate equipment 

sets, highly-specialized personnel, and considerable 

amounts of time. The extensive resources for sampling 

are required because there are no test methods, continuous emissions monitoring equipment, or direct reading 

instruments that can analyze all emissions concurrently. 

While some emissions such as CO2

 can be quantified 

at low costs with easily procured instruments, the vast 

majority of analytes of interest require ample time and 

money. Previous research has studied the feasibility of 

using emissions such as CO2 as surrogates to estimate 

other emissions constituents. However, surrogate testing 

may be only informative for exposure assessments in 

austere conditions and does not replace the need for a 

full suite of testing.29 It is important to note here that 

detailed emissions analysis is necessary for the DoD to 

definitively understand emissions from potential WTE 

systems before they are developed and fielded. Therefore, a prioritized list of emissions and standardized 

testing methodology must be established to maximize 

efficiency and minimize testing costs.

DoD Energy Initiatives

At the time of this writing, the DoD approaches the 

concepts of operational energy very differently than it 

has in the past. This shift is in part a result of current 

budgetary environments, but also the acknowledgement of senior leadership that energy efficiency can be 

a force multiplier if applied correctly. Lessons learned 

from OIF/OEF highlight that capabilities which reduce 

energy consumption, simplify logistics, and impart 

greater combative stamina to the Warfighter are of unquestionable value. To that end, there are several efforts 

within the DoD focused on aligning US military forces 

with future strategic goals, such as reductions in energy 

dependence and increased energy efficiency, without 

hampering the ability of the Warfighter. As a specific 

example, the Marine Corps Expeditionary Energy Office was established on October 1, 2009, charged with 

the mission to “analyze, develop, and direct the Marine 

Corps’ energy strategy in order to optimize expeditionary capabilities across all warfighting functions.” 30

The Marine Corps Initial Capabilities Document for Expeditionary Energy, Water and Waste 31 (ICD) outlines 3 

primary objectives: (1) Achieve resource self-sufficiency on the battlefield, (2) reduce energy demand in platforms and systems, and (3) reduce the overall footprint 

in current and future expeditionary operations. The 

ICD formalized the need for analyzing waste as a step 

forward to achieve energy efficiency, curtail dependency, and reduce resource requirements to handle waste. 

Moreover, the ICD confirmed that waste management is 

inextricably tied to energy efficiency and consumption. 

In the most illustrative example, waste disposal in austere environments using burn pits can require in excess 

of a pound of fuel for disposal of 2 pounds of nonhazardous solid waste. This new focus on waste, coupled 

with waste management as an integral part of environmental considerations in base planning, has opened the 

possibilities for technology that can fill the dual role of 

waste disposal and energy production through WTE 

technologies.

Waste-to-energy technology is not an entirely novel 

concept; commercial industry has honed the technology 
90 http://www.cs.amedd.army.mil/amedd_journal.aspx

to marketable viability both domestically and internationally. In the private sector, the use of WTE technology has been gaining momentum as a potential tool to 

transform solid waste into usable energy which supports 

efforts to manage waste in a closed loop fashion.32 However, DoD’s requirements to deploy equipment dictates 

the miniaturization, containerization, and application 

of these systems into harsh austere environments that 

are new design challenges for the technology. Currently, 

waste handling in deployed environments can be accomplished several different ways; US forces managing disposal, contractor disposal, burying, contracting 

to third country nationals, incineration, burn pits, and 

burying, to name a few. However, in 2011, in response 

to concerns of exposure from burn pit emissions, DoD 

Instruction 5715.1933 established as policy:

...the prohibition of the disposal of covered waste in 

open-air burn pits during contingency operations, except in circumstances in which no alternative disposal 

method is feasible.33(p1)

Framing the Problem for DoD-Specific

Waste-to-Energy Systems

To effectively fill the gap created by the avoidance of 

burn pit use in deployed waste management plans, it 

is important to first understand the operating environment and nature of DoD’s problem.34,35 Compared to 

planning for US operations, or deployment into austere 

but permissive situations, deployed waste management 

at the far forward tactical edge faces challenges which 

are unique to these potentially hostile and expeditionary 

settings. Common operational environment considerations include items such as geography, local economy, 

climate, and time. However, the threat of enemy hostilities, which are continually adapting to exploit perceived 

weaknesses, are the defining characteristic that differentiates DoD applications from other austere WTE solutions such as island nations, remote rural communities, 

etc. In past operations, open-air burning of solid waste 

allowed deployed personnel to maintain focus on essential tactical tasks in the face of enemy threat. However, 

technological advancements have rendered rudimentary 

burning and similar methods far less advantageous. It is 

now necessary to choose a suitable alternative to burn 

pits that provides the same simplicity, convenience, and 

reliability without exposing service members to hazardous air emissions.

Guided by efforts to promote health and sustainability, 

the “objective of waste management is to minimize the 

potential harm and cost” of waste, which may be accomplished by “developing options that are feasible, suitable, 

and sustainable.” 36(p1-2) To better understand the nature 

of the problem and how to develop alternative disposal 

options, limitations should also be considered.34 Waste 

disposal operations are strictly regulated by federal law 

in the United States for garrison and training. However, 

waste disposal policies mandated in the United States 

do not always extend into deployed environments due 

to constrained resources and shifted priorities—force 

protection often supersedes environmental protection 

in hostile environments. Expeditionary manpower, time, 

and resource limitations demand careful consideration. 

Expeditionary forces must conduct combat operations, 

in addition to day-to-day waste management, with only 

the manpower and resources organic to their unit. This 

fact will influence the development of disposal options 

and the respective attribute trade-offs. For example, 

contracting local nationals to conduct waste disposal is 

cost efficient, benefits the local economy, and frees military personnel to focus on tactical tasks, but it also exposes personnel to the possibility of attack from within 

their contingency base. Similarly, although WTE systems have the potential to reduce energy consumption 

and volume of waste, they cannot do so at the cost of 

continual manning, excessive segregation/pretreatment 

of input waste, or extensive maintenance.

Austere contingency base camps continually face enemy 

threats and pose particular challenges that presuppose 

the “one-size-fits-all” WTE solution that city-sized US 

installations often enjoy (eg, large waste feedstock supply and ample non-Warfighter contractor support). In 

addition, mere interservice differences in concepts of 

operations, tables of organization, tables of equipment, 

and budgets also impose limitations on joint courses 

of action. For example, naval shipping, where space is 

already limited, must conform to specific container dimensions and weights. Air Force lift capabilities face 

another strict set of shipping requirements related to 

container volume and weight. Army and Marine Corps 

units have different organic heavy equipment capabilities, which also affect the physical design and transportability of a candidate WTE system. Not surprisingly, 

these differences, among others, have driven the development of widely varying WTE systems that military 

decision-makers may consider in disposal planning.

Nonetheless, voids still exist in information relating to 

the deployed waste stream and WTE systems. Due to 

natural variability, there is still much uncertainty about 

deployed life-cycle disposal costs, waste composition, 

generation rates, and the available latent energy, despite 

the development of a standard deployed “waste recipe.” 

This uncertainty will be a source of risk in both acquisition and planning. Based on a typical military waste 

stream feedstock, data should also be collected on net 

energy conversion efficiency, combustion efficiency, 

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations
October – December 2016 91

The Army Medical Department Journal

and air emissions. Therefore, standardized WTE test 

procedures and analysis reflecting the unique deployment environment should be implemented to improve 

the deployability and effect on force protection of expeditionary waste management.

Deployed Waste Management Practices

Waste management requires attention and resource 

dedication across the spectrum of military operations 

as a function of environmental considerations. Waste 

management must be deliberate whether the conditions 

are garrison and training activities, initial and mature 

combat operations, or peacetime operations such as 

foreign humanitarian aid or humanitarian assistance/

disaster relief scenarios. The joint Army/Marine Corps 

publication Environmental Considerations 1

 comprehensively outlines the commander’s responsibility to ensure adherence to such considerations. Improper waste 

management has the potential to adversely affect force 

health protection through uncontrolled spreading of disease (disease vectors), exposure to hazardous materials, 

and exposure to hazardous waste. Understandably, doctrine guides commanders to place a lower priority on 

environmental considerations as necessitated by a threat 

analysis. However, if feasible, effective waste management can reduce logistical burden, promote host-nation 

good will, and enhance postconflict stability.36

As discussed earlier, similar to the wideranging scope of environmental considerations, military base sizes and planning 

factors have an extensive range as well. 

The joint Army/Marine Corps publication 

Base Camp2

 details the factors that influence establishing and maintaining military 

base camps. Base camps are classified into 

4 sizes by population as shown in Table 1.

Smaller base camps tend to be more unique and military-specific with focused combat functions. Larger 

camps tend to function in a manner similar to small cities, as they are hubs for personnel and logistics to sustain forward extended forces.

Military Specific Waste Characterization

A full understanding of base camp waste streams (composition and characteristics) is important to inform the 

research and development of WTE systems. Aside from 

percentage composition of various waste categories, the 

actual physical and chemical characteristics help determine WTE technology suitability and its effective design. Characteristics of specific weight (or bulk density), 

moisture content, chemical composition through an “ultimate analysis,” and energy content determination will 

encourage the best WTE system design. Each characteristic affects how the WTE system will perform with the 

waste stream that it thermochemically treats (ie, combustion). Moreover, waste streams also vary according 

to base camp size and mission set.*

Through the Joint Deployable Waste to Energy (JDW2E) working group, DoD is considering WTE as a 

possible solution to its waste management problems. 

Most historical waste stream characterizations have 

been performed on medium and large (Table 1) base 

camp sizes. However, JDW2E has determined that deployable containerized WTE implementation within the 

DoD will be at the extra small and small (Table 1) base 

camp sizes. Other than the waste analysis performed in 

the Philippines in conjunction with the bilateral 2015 

Amphibious Landing Exercise-Philippines (PHIBLEX), 

only one other US military waste stream characterization has been performed at smaller base camp sizes 

with the same methodology (Fort Hunter Liggett (FHL), 

California). The FHL study was performed on the 4th 

Naval Construction Battalion (N≈500) during their field 

exercise.37

The FHL and the PHIBLEX studies used the American Society of Testing and Materials (ASTM) D5231-

92(2008) 38 as the framework for their waste composition methodology. This is also a common standard used 

for other waste composition studies.39-42

Waste stream analysis has been affected by 

the characterization methodology used.43,44

Therefore, JDW2E has narrowed its focus 

on waste characterizations that adhere with 

this common methodology to aid in comparison studies.

The JDW2E community is focused on 

contingency base camps for use of deployable WTE 

systems because contingency base camps have historically used open-air burn pits as a primary waste disposal option. Although the PHIBLEX 2015 study was 

performed during an exercise, the waste stream closely 

resembled the contingency base camp environment due 

to the types of simulated combat operations (eg, live-fire 

ranges, close-air support integration, logistics convoys) 

and the activities performed within the camp (eg, maintenance on vehicles, medical tents, billeting, mess tents 

serving field rations, etc). The PHIBLEX 2015 study 

was the only military waste stream study that has met 

all 3 requirements of a smaller base camp size, ASTM 

standard methodology, and contingency base camp focus. Additionally, to date it is the only military waste 

Table 1. Base Camp Classification by Population.2

Base Camp

Classification

Population

Extra Small 50-299

Small 300-1,999

Medium 2,000-5,999

Large ≥6,000

*Internal, restricted access military document not accessible by 

the general public.
92 http://www.cs.amedd.army.mil/amedd_journal.aspx

study that was performed in the Pacific 

theater, an area to which the United States 

has increased its focus of effort.45-47

The waste composition study was conducted on the waste stream produced 

by US Marines at the Crow Valley base 

camp.* The population at Crow Valley 

was 800-1,300, so the camp was classified 

as small.2

 The waste was predominantly 

composed of food (28.2%), cardboard 

(19.7%), and total plastics (15.3%). The 

waste stream revealed military and contingency-types of waste due to the highly 

combat-simulated base camp environment 

and activity. Ammunition (5.56x45mm 

NATO), medical waste (used intravenous 

kit with needles), and hazardous waste 

(rags soaked with petroleum, oils, and lubricants) were found in the waste stream, 

despite prohibitions against such disposal. 

Figure 3 shows the composition of the 

PHIBLEX waste stream. Table 2 presents 

the 21 different waste categories that were assigned during the PHIBLEX study.

Waste Groupings and Comparison

In an attempt to distill the salient points of the various waste categories into an analysis with more utility 

geared for WTE technology, 4 “waste groupings” were 

created to standardize the waste compositions for objective comparison: total plastics, moisture, combustibles, 

and metals/inorganics/other. Statistical comparisons 

were made after combining the waste categories into 

these 4 groupings.* In a government report,26 the Army 

Research Laboratory (ARL) redefined the original 4 

waste categories into 10 waste categories as the ASTM 

standard recommended.38 Their analysis compared 

various military waste compositions 

and created a standard waste recipe 

presented in Table 3. When these 10 

categories are grouped again into the 

4 waste groupings, superficial percentage comparison suggests that the 

PHIBLEX 2015 waste is similar to 

the proposed standard waste recipe as 

shown in Table 4. However, detailed 

statistical analysis revealed that percentage composition did not suggest 

waste stream equivalency.* This was 

verified by using the nonparametric Wilcoxon/Kruskal-Wallis Rank 

Sums Test and the Dwass, Steel, Critchlow-Fligner Multiple Comparisons Test where P values were compared 

against α=0.1.

In-depth statistical comparison may suggest that there is 

a difference. Inherent food waste difference is acknowledged between the 2 waste streams (actual vs representative); for example, the Army Research Laboratory 

report 26 used dog food as an easily obtainable, shelfstable surrogate to simulate the food waste observed in 

an actual base camp. Additionally, clean and new (virgin) plastics were used instead of moisture-laden, soiled 

plastics that are typically found in the field.

Energy From Waste: A Possible Solution

Waste characterization studies are 

the backbone of understanding military waste and the data collected is 

essential for WTE technology development. The studies form the basis 

of what materials and waste mixtures 

are used in simulated predetermined 

waste recipes, the starting point to test 

systems for DoD application, energy 

recovery potential, volume reduction, 

and health and environmental impact. 

As discussed earlier, emissions can 

be significantly lowered by burning 

waste in a controlled environment, 

where high temperatures can be maintained and smoldering conditions (which produce higher emissions) can 

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations

Figure 3. Composition of waste stream for the Crow Valley base camp in the 

Philippines during PHIBLEX 2015. Note: all 7 plastics categories were consolidated into one data component for this chart.

Other, Organic

Yard Waste

Other, Inorganic

Glass

Rubber

Textiles

Hazardous Materials

Metal, Ferrous

Liquid

Metal, Non-Ferrous

Wood

Paper, Mixed

Plastics

Cardboard, Corrugated

Food

Metal, nonferrous

Food

Plastics

Paper, mixed

Wood

Other, organic

Yard waste

Other, inorganic

Glass

Rubber

Textiles

Metal, ferrous

Liquid

Hazardous Materials

Cardboard, corrugated 20%

15%

14%

0.01%

0.07%

0.15%

0.4%

0.6%

1.1%

1.5%

2%

4%

7%

6%

28%

0% 5% 10% 15% 20% 25% 30%

Percentage by Net Weight (mean)

Table 3. Army Research Laboratory 

Proposed Waste Standard Recipe.26

Categories Composition

1 Cardboard 15%

2 Mixed paper 10%

3 Food Waste 32%

4 Total Plastics 15%

5 Wood 14%

6 Metals 6%

7 Glass 1%

8 Rubber & Neoprene 1%

9 Textiles 3%

10 Misc/Other 3%

*Internal, restricted access military document not accessible by 

the general public.
October – December 2016 93

The Army Medical Department Journal

be eliminated.24 Consequently, destruction of waste in 

a controlled and contained manner increases the possibility of harnessing usable energy from waste. There 

have been several technologies developed to handle 

municipal solid waste (MSW) in WTE systems, each 

with specific design characteristics such as throughput, 

preprocessing, power output, etc. Figure 4 outlines currently available processes to transform waste into thermal energy and depicts the major steps involved for each 

Table 2. Waste Categories and Generation.

Categories Description Content Example Mean

Composition

[%]

Average Daily

Generation

[lbs]

1 Polyethylene

Terephthalate

(PET)

Resin Code #1: Most common thermoplastic polymer resin consists of polymerized 

units of the monomer ethylene terephthalate, with chemical formula (C10H8O4

)

n

Water bottles; beverage/food/

cleaner bottles

2.5% 97.4

2 High-Density

Polyethylene

(HDPE)

Plastic Resin Code #2: A polyethylene thermoplastic made from petroleum

Bottles, trash/cereal bags, sauce 

packets

0.5% 20.3

3 Polyvinyl Chloride (PVC)

Plastic Resin Code #3:Third-most widely produced plastic, chemical formula (C2H3Cl)n

Film (cling wrap), construction 

materials

0.4% 5.0

4 Low-Density

Polyethylene

(LDPE)

Plastic Resin Code #4:A thermoplastic 

made from the monomer ethylene

MREs food bags/wrappings 6.8% 321.2

5 Polypropylene

(PP)

Plastic Resin Code #5: A thermoplastic polymer with chemical formula (C3H6

)

n

Cereal containers, medicine bottles, 

straws 

1.1% 67.2

6 Polystyrene 

(PS)

Plastic Resin Code #6: Synthetic aromatic 

polymer, chemical formula (C8H8

)

n

Styrofoam, utensils, disposable 

food containers, MRE packaging

2.0% 98.9

7 Other Plastics Plastic Resin Code #7: Other Plastics not 

categorized/labeled with Code #1-6

Reusable water bottles, UGR food 

trays

2.0% 82.6

8 Food Waste Discarded solid food leftovers/scraps originally intended for human consumption

Field chow hall, UGRs, or MREs 28.2% 1510.7

9 Mixed paper Recyclable paper High-grade paper: office paper; 

paper trays

14.3% 498.3

10 Corrugated

Cardboard

Corrugated heavy-duty paper or paperbased fiberboard consisting of a fluted 

corrugated sheet and one or two flat 

linerboards.

Boxes 19.7% 1131.3

11 Metals, Ferrous Alloys that contains a significant amount of 

iron. Ability to magnetize.

Food-grade cans from UGRs; banding Wire

2.4% 98.9

12 Metals,

Nonferrous

Alloys that do not contain a significant 

amount of iron. Does not magnetize.

Aluminum cans, individual MRE 

packages

5.5% 194.4

13 Other Organics Combustible waste that does not fit in other 

waste categories

Insects 0.0% 0.1

14 Other

Inorganics

Noncombustible waste that does not fit in 

other waste categories

Concrete, asphalt, soil, stone,

cigarette ash

0.2% 6.0

15 Wood All wood types from trees or woody plants Bamboo, construction wood

(lumber), pallets

6.9% 370.1

16 Yard Waste Biodegradable waste which was once a 

plant (garden waste)

Leaves, parts of bushes/vegetation 0.1% 0.0

17 Liquids Any fluid Liquids remaining in bottles 4.0% 176.3

18 Glass Transparent solid composed of SiO2 Vehicle windshields, glass bottles 0.4% 12.8

19 Hazardous 

Waste

Substance that poses a threat to human or 

environmental health

Needles, medical waste with blood, 

MRE heater

1.5% 59.3

20 Textiles Cloth that was woven with fibers like thread 

or yarn

Socks, uniforms, parachute cord, 

t-shirts 1.1% 44.2

21 Rubber Highly elastic solid substance (synthetic or 

natural) 

Tires, seals from ordnance 

packaging 0.6% 26.0

100.0% 4820.7

Table 4. Comparison of Waste Groupings.

4 Waste Groupings PHIBLEX

2015

ARL Standard

Waste Recipe26

Total Plastics 15.3% 15%

Moisture 32.1% 32%

Combustibles 42.7% 43%

Metals/Inorganics/Other 9.9% 10%

Total 100% 100%
94 http://www.cs.amedd.army.mil/amedd_journal.aspx

method. Not unexpectedly, there are physical and thermochemical limits to the current technology that rely on 

waste stream input volume and footprint requirement. 

With that in mind, there are only 4 physical processes 

that are practical to support processing of military-specific waste at extra-small and small base camps: direct 

combustion, combustion, pyrolysis, and gasification.49

Direct combustion is a relatively simple process, as it 

requires minimal preprocessing of the waste feedstock. 

Drawbacks to direct combustion are the creation of fly 

ash, absence of scrubbing systems to remove toxins 

from air emissions, and, qualitatively, negative public 

perception.49 Nonetheless, despite the lack of dedicated 

air emission handling systems, direct combustion systems usually provide better burn conditions, increased 

combustion efficiency, higher temperatures, reduced 

smoldering conditions, and cleaner emissions over conventional burn pits. Direct combustion systems provide 

a technologically simple method for waste disposal 

by achieving volume reduction and relatively cleaner 

emissions.

Another option is thermochemical processes that convert waste into a secondary energy (liquid fuel) which 

“allows for a cleaner and more efficient process...smaller 

flue gas volumes allow reduced gas cleaning equipment 

sizes” and “are compatible with gas turbines and gas 

motors, characterized by a high electrical efficiency.” 50

As WTE systems aim for maximum efficiency and energy recovery, their designs become exceedingly complex (such is the case in gasification and pyrolysis-based 

systems), the physical characteristics and “quality” of 

the fuel source become increasingly important. Municipal solid waste is a heterogeneous fuel source. It varies widely in moisture content, material size, and the 

composition is generally at the mercy of the supported 

community. Processes to transform waste to a more 

homogenous refuse derived fuel are available and have 

been investigated. Refuse derived fuel (RDF) can be 

generated from MSW by “shredding, screening, sorting, drying and/or pelletization in order to improve the 

handling characteristics and homogeneity” of MSW.50

The Bosmans and Helsen50 review of WTE technologies focuses on RDF, due to the fact that systems such 

as pyrolysis and gasification require homogenous waste 

streams to achieve maximum efficiency. Transforming 

and processing waste is an additional design consideration that adds complication to the waste disposal process and must be carefully considered while designing 

a mobile and dependable solution for deployed forces in 

austere environments.

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations

Figure 4. Biomass energy sources. Adapted from Energie Aus Biomass49 with permission of its authors.
October – December 2016 95

The Army Medical Department Journal

System complexity is an extremely important consideration. Generally, air emissions decrease as system 

complexity increases (ie, burn pits to gasification/pyrolysis). The tradeoff for better emissions is increased 

system intricacy and overall weight. Figure 5 illustrates the progression and tradeoff expectations for 

transitioning from burn pits to various WTE systems.

Removing toxins from emissions is an important 

consideration for WTE systems and can be achieved 

by adding various cleanup technologies (known collectively as air pollution control devices) to exhaust 

systems. Adding scrubbing systems to any WTE 

technology raises the complexity of a system and 

must be carefully considered for use in contingency 

environments where skilled maintenance support 

will be limited. Irrespective of specific technology approach, WTE broadly promises volume reduction of 

waste in excess of 95% of original dimensions and reduced emissions as compared to open burn pits. Waste 

volume reduction is directly aligned with the strategy 

established by the DoD as outlined in the Strategic Sustainability Performance Plan.

51

The goal is for the DoD to provide a safer alternative 

than burn pits to service members deployed in an austere environment and not hinder or unnecessarily burden their mission, potentially turning what is currently 

a logistical burden into a potential energy resource. If a 

WTE system is developed for this purpose, testing and 

development protocols must align to simultaneously address the health risk concerns, waste processing requirements, and DoD specific deployment considerations 

(maintenance, durability in shipping, ability to operate 

in diverse environments, mobility, etc). The only way to 

accomplish this goal is accurate problem definition and 

conscientious service member input during all stages of 

system development.

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Burn Pits Direct Combustion Gasification/Pyrolysis Plasma Treatment

SIMPLE COMPLEX

Higher

Lower EMISSIONS

Waste-to-Energy Technology
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1442. doi:10.1093/aje/kwp287.

21. Szema AM, Salihi W, Savary K, Chen JJ. Respiratory symptoms necessitating spirometry among soldiers with Iraq/Afghanistan war lung injury. J Occup Environ Med. 2011;53(9):961-965. doi:10.1097/

JOM.0b013e31822c9f05.

22. Abraham JH, DeBakey SF, Reid L, Zhou J, Baird 

CP. Does deployment to Iraq and Afghanistan 

affect respiratory health of US military personnel? J Occup Environ Med. 2012;54(6):740-745. 

doi:10.1097/JOM.0b013e318252969a.

23. Woodall BD, Yamamoto DP, Gullett BK, Touati 

A. Emissions from small-scale burns of simulated 

deployed US military waste. Environ Sci Technol. 

2012;46(20):10997-11003. doi:10.1021/es3021556.

24. Aurell J, Gullett BK, Yamamoto D. Emissions 

from open burning of simulated military waste 

from forward operating bases. Environ Sci Technol. 

2012;46(20):11004-11012. doi:10.1021/es303131k.

25. Environmental Protection Agency. Standards 

of Performance for New Stationary Sources. 40 

CFR Part 60. Available at: http://www.ecfr.gov/

cgi-bin/text-idx?tpl=/ecfrbrowse/Title40/40cfr60_

main_02.tpl. Accessed May 4, 2016.

26. Margolin JA, Marrone PA, Randel MA, Allmon WR, Mclean RB, Bozoian PM. Test Standards for Contingency Base Waste-to- Energy 

Technologies. Adelphi, MD: US Army Research 

Laboratory; August 2015:49-58. Report No. ARLTR-7394. Available at: http://www.dtic.mil/cgibin/GetTRDoc?Location=U2&doc=GetTRDoc.

pdf&AD=ADA623363. Accessed May 4, 2016.

27. Technical Guide 230: Environmental Health Risk 

Assessment and Chemical Exposure Guidelines 

for Military Personnel. Aberdeen Proving Ground, 

MD: US Army Public Health Command; 2013;C-1. 

Available at: https://phc.amedd.army.mil/PHC%20

Resource%20Library/TG230.pdf. Accessed May 4, 

2016.

28. Overseas Environmental Baseline Guidance 

Document: DoD 4715.05-G. Washington, DC: US 

Department of Defense; 2007. Available at: http://

www.dtic.mil/whs/directives/corres/pdf/471505g.

pdf. Accessed May 4, 2016.

29. Schmidt MA. Health Risk Assessments of Waste 

Combustion Emissions Using Surrogate Analyte 

Models [master’s thesis]. Wright-Patterson AFB, 

Ohio: Air Force Institute of Technology; 2013. 

Available at: http://www.dtic.mil/dtic/tr/fulltext/u2/

a582122.pdf. Accessed May 4, 2016.

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations
October – December 2016 97

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30. United States Marine Corps Expeditionary Energy Strategy and Implementation Plan. Washington, DC: Headquarters, US Marine Corps; 2011:5. 

Available at: http://www.hqmc.marines.mil/Por

tals/160/Docs/USMC%20Expeditionary%20Ener

gy%20Strategy%20%20Implementation%20Plan

ning%20Guidance.pdf. Accessed May 4, 2016.

31. United States Marine Corps. Initial Capabilities 

Document for USMC Expeditionary, Energy, Water, and Waste. Quantico, VA: Marine Corps Combat Development Command, Combat Development 

and Integration; 2011. Available at: http://www.

hqmc.marines.mil/Portals/160/Docs/USMC%20

E2W2%20ICD.pdf. Accessed May 4, 2016.

32. Bosmans A, Vanderreydt I, Geysen D, Helsen 

L. The crucial role of waste-to-energy technologies in enhanced landfill mining: a technology 

review. J Clean Prod. 2013;55:10-23. doi:10.1016/j.

jclepro.2012.05.032.

33. Department of Defense Instruction 4715.19: Use 

of Open-Air Burn Pits in Contingency Operations. 

Washington DC, US Department of Defense; 2011. 

Available at: http://www.dtic.mil/whs/directives/

corres/pdf/471519p.pdf. Accessed May 5, 2016.

34. Joint Publication 5-0: Joint Operation Planning. 

Washington, DC: Joint Staff, US Department of 

Defense; August 11, 2011. Available at: http://www.

dtic.mil/doctrine/new_pubs/jp5_0.pdf. Accessed 

May 5, 2016.

35. US Marine Corps. Marine Corps Warfighting 

Publication 5-1: Marine Corps Planning Process. 

Washington, DC: Headquarters, US Marine Corps; 

2010. Available at: http://www.marines.mil/Por

tals/59/MCWP%205-1.pdf. Accessed May 5, 2016.

36. Technical Manual 3-34.56/Marine Corps Interim 

Publication No. 4-11.01: Waste Management for 

Deployed Forces. 2013. Washington DC: US Department of the Army/ Headquarters, US Marine 

Corps; 2013. Available at: http://www.med.navy.

mil/sites/nmcphc/Documents/oem/TM-WasteManagement-for-Deployed-Forces.pdf. Accessed 

May 5, 2016.

37. Rotty L. Solid Waste Characterization Study, Fort 

Hunter Liggett, CA. Port Hueneme, CA: Naval 

Facilities Engineering Command, Engineering 

and Expeditionary Warfare Center; 2014. Report 

SSR-NAVFAC-EXWC-EV-1405.

38. ASTM D5231: Standard Test Method for Determination of the Composition of Unprocessed Municipal Solid Waste. West Conshohocken, PA: ASTM 

International; 2008. doi:10.1520/D5231-92R08.

39. Aphale O, Thyberg KL, Tonjes DJ. Differences in 

waste generation, waste composition, and source 

separation across three waste districts in a New 

York suburb. Resour Conserv Recycl. 2015;99:19-

28. doi:10.1016/j.resconrec.2015.03.008.

40. Al-Jarallah R, Aleisa E. A baseline study characterizing the municipal solid waste in the State 

of Kuwait. Waste Manag. 2014;34(5):952-960. 

doi:10.1016/j.wasman.2014.02.015.

41. Gidarakos E, Havas G, Ntzamilis P. Municipal solid waste composition determination supporting the 

integrated solid waste management system in the 

island of Crete. Waste Manag. 2006;26(6):668-679. 

doi:10.1016/j.wasman.2005.07.018.

42. Zeng Y, Trauth KM, Peyton RL, Banerji SK. Characterization of solid waste disposed at Columbia 

Sanitary Landfill in Missouri. Waste Manag Res. 

2005;23(1):62-71. doi:10.1177/0734242X05050995.

43. Beigl P, Lebersorger S, Salhofer S. Modelling municipal solid waste generation: a review. 

Waste Manag. 2008;28(1):200-214. doi:10.1016/j.

wasman.2006.12.011.

44. Edjabou ME, Jensen MB, Götze R, et al. Municipal solid waste composition: sampling methodology, statistical analyses, and case study evaluation. Waste Manag. 2015;36:12-23. doi:10.1016/j.

wasman.2014.11.009.

45. Panetta LE. The US Rebalance Towards the AsiaPacific. US Department of Defense website. 2012. 

Available at: http://www.defense.gov/speech

es/speech.aspx?speechid=1681. Accessed May 5, 

2016.

46. Sustaining US Global Leadership: Priorities for 

21st Century Defense. Washington, DC: US Department of Defense; January 2012. Available at: 

http://archive.defense.gov/news/Defense_Strate

gic_Guidance.pdf. Accessed May 5, 2016.

47. A Cooperative Strategy for 21st Century Seapower. Washington, DC: US Department of the Navy; 

March 2015. Available at: http://www.navy.mil/lo

cal/maritime/150227-CS21R-Final.pdf. Accessed 

May 5, 2016.

48. Kaltschmitt M, Hartmann H, Hofbauer H, eds. 

Energie Aus Biomasse. 2nd ed. Berlin, Germany: 

Springer-Verlag GmbH; 2009. http://www.springer.

com/us/book/9783540850946. Accessed February 

25, 2016.

49. Amack DC. Waste-to-Energy Decision Support 

Method for Forward Deployed Forces [master’s 

thesis]. Wright-Patterson AFB, Ohio: Air Force 

Institute of Technology; 2014. Available at: http://

www.dtic.mil/dtic/tr/fulltext/u2/a599359.pdf. Accessed May 5, 2016

50. Bosmans A, Helsen L. Energy from waste: review of thermochemical technologies for refuse 

derived fuel (RDF) treatment. Paper presented at: 

Third Annual Symposium on Energy from Biomass and Waste; November 8-11, 2010; Venice, 

Italy. Available at: https://lirias.kuleuven.be/bit

stream/123456789/276089/2/ABosmans2010.pdf. 

Accessed May 5, 2016.
98 http://www.cs.amedd.army.mil/amedd_journal.aspx

51. DoD Strategic Sustainability Performance Plan FY 

2014. Washington, DC: US Department of Defense; 

2014. Available at: http://denix.osd.mil/sustainabil

ity/upload/DoD-SSPP-FY14-FINAL-w_CCAR.

pdf. Accessed May 9, 2016.

Authors

Capt Barnes, Capt Suh, and Capt Crutchfield are graduate students at the US Air Force Institute of Technology, 

Wright-Patterson Air Force Base, Dayton, Ohio.

Dr Baird is Chief, Environmental Medicine Division, US 

Army Public Health Center, Aberdeen Proving Ground, 

Maryland.

Mr Amina is Senior Analyst, Global Defense, with the 

J81 Innovation and Experimentation Division, US Pacific Command, Camp H. M. Smith, Hawaii.

Lt Col Eninger is an Assistant Professor, US Air Force 

Institute of Technology, Wright-Patterson Air Force 

Base, Dayton, Ohio.

Bridging the Gap Between Burn Pits and Waste-to-Energy Technology:

Safe and Effective Waste Management in Contingency Operations

US Marines observing smoke plumes from an open air burn 

pit in Afghanistan, September 2008 (DoD image).
October – December 2016 99

The Performance Triad and the Military Family

In 2013, the Army Surgeon General’s office unveiled 

an innovative health promotion and fitness plan known 

as the Performance Triad (often simply referred to as 

“the Triad”).1

 The Triad is the first initiative of the larger 

“System for Health” concept. The mission of a System for 

Health is to involve all aspects of the military community in the goal of promoting health and wellness, preventing illness and injury, providing high quality care, 

and positively influencing behavior and environments 

where beneficiaries live, work, and play.2

 The Army 

Medicine website describes the Performance Triad and 

its place within the System as:

A comprehensive plan to improve readiness and increase 

resilience through public health initiatives and leadership engagement. The Triad is the foundation for Army 

Medicine’s transformation to a System for Health, a 

partnership among Soldiers, Families, Leaders, Health 

Teams and Communities to promote Readiness, Resilience and Responsibility. The System For Health: 

MAINTAINS health through fitness and illness/injury 

prevention, RESTORES health through patient-centered 

care, and IMPROVES health through informed choices 

in the life space.2

COL Deydre Teyhen, current director of the Army 

Surgeon General’s System for Health, described the 

program to the Army Times as a tool to help Soldiers 

understand the effect of altering unhealthy habits and 

achieving better fitness through “the small, simple 

changes they can make.” 1

 The goal is to enhance overall 

fitness through development of an individual plan that 

helps Soldiers realize the positive health outcomes that 

accompany healthy choices. These ideas are reflected 

in the program’s basic message: engage in activity, improve nutrition, and get quality sleep. Though the Triad premise is simple, the overall concept represents a 

unique shift away from compartmentalized fitness and 

towards holistic prevention and proactivity practices.3

The Triad also widens the lens to recognize the positive 

effect that a Soldier’s family can have on the Soldier’s 

overall health. A recent demographics profile found 

55.3% of the active duty military community is married, 

42.2% have children, and family members outnumber 

active duty service members by more than 450,000.4 

These statistics indicate a potentially robust role for 

family integration into the Triad. Military families excel 

as members of an active community. One study showed 

that military spouses exercise substantially more than 

comparable civilian groups, and military children tend 

to participate in physical activity more than other children their age.5

 Military families have also been shown 

to provide a strong foundation for mental well-being, social support, and resilience in the face of the uncertainty 

characteristic to military service.6,7 Overall, a Soldier’s 

family likely plays a key role in implementing lifestyle 

changes related to improving activity, nutrition, and sleep.

Military Pets: Four-Legged Family

Companion animal ownership is com mon within military families. A recent report from the US Army Public 

Health Center (not publicly accessible)8

 enumerating patient records from all veterinary facilities located on Department of Defense installations worldwide shows that 

there are currently over 360,000 pets registered at military facilities in the contiguous 48 United States, and 

over 86,000 registered at facilities outside of those states 

(mainly Europe and Asia). Not only does the military 

community have an abundance of pets, most consider 

pets to be a part of the family. A survey of 896 military 

families with pets showed that 98% considered their pet 

a family member or close friend, 75% said that their pet 

was of great importance to the family at all times, and 

72% indicated that their pet had “people status” within 

the family.9

 Another survey examining military families 

with pets transferring from Hawaii found that 99% considered their pets as family members, and 96% had at 

least one family member experience temporary or chronic sadness if the pet had to be left behind.10 Despite the 

difficulties, military families form strong attachments 

to their pets and have been shown to be more willing 

to accept the additional responsibilities associated with 

ensuring their pet is a part of the frequent relocations 

inherent to service.11 In short, military pet owners clearly appreciate their 4-legged family members, but many 

may not realize that the relationship has the potential to 

boost their health.

Health Benefits and the Human Animal Bond:

A Review

Researchers have investigated the human-animal bond 

and its effect on overall well-being for years. In addition 

Animal-Assisted Health and the

 Performance Triad

MAJ M. Todd French, VC, USA
100 http://www.cs.amedd.army.mil/amedd_journal.aspx

to the abundance of anecdotal evidence that animals 

“just make us happy,” there are evidence-based data that 

support the positive association between animal ownership and long-term health. The evidence supporting 

companion animals and cardiovascular health is particularly persuasive.

In a landmark study examining one year survival time 

in heart attack victims after discharge from a coronary 

care unit, Friedmann et al found that pet owners survived at a rate over 4 times greater (28%) than non-pet 

owners (6%).12 Allen et al discovered that high blood 

pressure and heart rate could be significantly reduced 

by way of pet ownership, even in a population at risk for 

cardiovascular disease (preexisting hypertension) engaged in a high stress career (stockbrokers).13 Anderson 

et al, in a study of 5,700 (784 pet owners), also found 

that sharing a house with a companion animal was not 

only associated with lower systolic blood pressure and 

heart rate, but significantly lower blood cholesterol and 

triglyceride levels.14 Several other studies have also 

connected pets in the household to heart health.15-17 In 

fact, the data linking the two is so convincing that the 

American Heart Association released a policy statement 

indicating that pet (particularly dog) ownership is probably associated with decreased cardiovascular disease 

risk, and may play a causal role in disease prevention.18

Cardiovascular health is not the only health benefit derived from pet ownership. Pets have also been shown 

to positively influence total health and well-being. For 

instance, a 10-month study on adults adopting animals 

from an animal shelter found a significant reduction in 

participants’ minor health problems for the entire 10 

months following adoption.19 Other studies have provided compelling evidence that owning cats and dogs 

as a child can actually decrease the likelihood of acquiring asthma or allergies.20-22 Researchers have also provided empirical data to strengthen anecdotal claims that 

pets “just make us happy.” Odendaal discovered that 

hormone levels of dopamine and endorphins associated 

with happiness and well-being increase following only 

30 minutes of dog interaction—and the same increases 

were observed in the dogs.23 Lastly, dog walking and interaction has become a recommended method to prevent 

chronic disease.24

Pets not only help prevent chronic disease, they promote 

health through a variety of avenues. The consensus in 

the scientific community is that pets do a remarkable job 

of increasing physical activity, improving our mood and 

emotional state, decreasing mental stress, and providing companionship.25 In addition to the obvious health 

benefits of increased physical activity, decreasing stress 

and providing social support through companionship 

may be the most significant role that pets play in human 

health.

Stress management likely represents an essential gateway to health for service members. A recent index of 

job stress scores puts military service behind only firefighting as the most stressful job in the United States.26

While a certain amount of intermittent stress can benefit 

the brain and body, a high degree of stress can be harmful.27 Stress overload can eventually exhaust the ability to adapt and lead to deleterious and chronic health 

changes.28

Due to its ease of collection, stress researchers typically 

correlate reductions in stress to reduction in the stress 

hormone, cortisol, in saliva.29 This method translates 

well to human-animal bond research as it is quick to 

measure stress response even during brief interactions. 

For example, Odendaal showed that cortisol reduction 

was significant in just a 30-minute session with a dog.23

Barker et al mirrored those results revealing that cortisol levels in healthcare professionals, another high stress 

career, could be reduced after as little as 5 minutes of interacting with a hospital visitation dog.30 Cortisol reduction is also used as a marker to determine the success 

of using service dog training programs to treat service 

members suffering from posttraumatic stress disorder.31

Fortunately, similar research reveals that dogs (even 

those enlisted in visitation programs) have reductions 

in cortisol as well when interacting with humans.23,32,33

Beyond this experimental evidence on stress reduction, 

pet owners consistently indicate that they just “feel” that 

pets reduce their stress levels.34,35

Social support is an integral, though difficult to measure, 

path through the gateway to better health. The evidence 

linking social support to overall well-being and host 

resistance to disease is strong.36-38 Thankfully for pet 

owners, animals play a useful part in the family social 

support network. Not only do pets offer direct support 

through the close owner relationship, they support indirectly by acting as a “social ice breaker.” 35 In a 2-tiered 

study examining dogs as social catalysts, McNicholas 

et al discovered that an individual performing normal 

daily activities with a dog had an increased frequency of 

social interactions, especially with strangers, when the 

dog was present irrespective of the way the individual 

was dressed.39 Another study investigating the behavior 

of 1,800 pedestrians passing an adult participant with a 

dog, a teddy bear, or a plant found that dogs facilitated 

the most reliable social interactions.40 Naturally, pets 

have been shown to also promote pro-social and learning behaviors in children.41

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October – December 2016 101

The Army Medical Department Journal

Animal-Assisted Health and the Triad:

Forming Actionable Goals

The scientific literature certainly fortifies the family 

pet’s role in supporting long term health, stress reduction, and the family social network. The question becomes, “how does this support help military families 

make Triad goals actionable?” In outlining the Performance Triad, Army Medicine mentions that a key component to goal setting is to focus on improving health 

within the life space. The life space refers to the approximately 525,000 minutes in a Soldier’s year that they are 

not with a healthcare provider (≈100 minutes).42 Obviously, time in the life space predominates. Those that 

adhere to the tenets of the Triad are urged to use this 

time to make “small, simple” lifestyle changes that will 

become their roadmap to better health and fitness. This 

is also the time that family pets can be most influential 

to improvements in activity, nutrition, and sleep. The 

author believes that this integration of pets into a cooperative health and fitness plan can best be described as 

“animal-assisted health.”

Engage in Activity: Animal-Assisted Health

The military culture, by its nature, supports an active 

population. Those who serve are reminded of this in 

everything from the rigors of basic training to the command designated time for physical fitness. Even the official songs of the 3 main military services allude to activity through verses inspiring their charges to, “march 

along,” “climb high,” and go “full speed ahead.” Service 

members are required to maintain a 

high level of physical fitness and are 

assessed on it frequently. The mere 

expectation of physical fitness, however, is not always enough to motivate 

obedience to activity. Predictably, attitude matters when it comes to adherence to an exercise program.43

Lack of motivation to perform scheduled physical training may be of particular concern in the military. Military members are normally expected 

to participate in a physical training 

program with their unit regardless 

of desire to attend. Lack of desire 

can lead to lack of focus during the 

program which may ultimately result 

in a lower level of fitness. The unfortunate consequence of a low fitness 

level is that it has been shown to be 

a predictor of musculoskeletal injury 

proneness in the military.44 Noted 

sports psychologist, Dr Bill Morgan, 

suggests that a paradigm shift in approach to exercise 

might increase loyalty to physical activity. His suggestion is to supplement nonpurposeful with purposeful exercise.45 The idea is that individuals will be more apt to 

adhere to exercise if it serves a purpose. Morgan also 

suggests that one of the most common purposeful activities is walking, or running, the family dog.

It is a given that dogs need to go outside several times 

a day to fulfill biological needs. One of those biological 

needs, of course, is the need to exercise. In his article, 

Morgan describes a presentation at the American College of Sports Medicine which points out how that can 

also be beneficial to the human need for exercise:

The famous Norwegian Psychiatrist, Dr Egil Martinsen, 

suggested in a colloquium he presented at the American 

College of Sports Medicine several year ago, that if a 

patient is considering an exercise machine, a dog would 

make for a good selection! Consider the situation where 

one awakens to discover that it is raining, snowing, or 

perhaps he or she just does not feel so well. It is very 

easy to put off a daily run or walk under these circumstances, but if the individual has a date (pact) with his or 

her dog, skipping the daily exercise is simply out of the 

question.45(p369)

Dog owners may make this “pact” without realizing 

just how mutually beneficial it can be. Several national 

surveys already indicate that dog owners exercise more 

than non-pet owners.14,46-48 This should, again, come 

as no surprise as walking a dog is a purposeful activity. It is theorized that dog walking 

may remove the barriers (ie, excuses) 

to participating in physical activity 

by using the social support channel 

created through the human-animal 

bond.24,47 Essentially, this theory expresses the common view that it is often more enjoyable to work out with 

a buddy.

The author believes that an increase 

in enjoyable exercise will accompany 

the realization that walking, or running, with the family pet is purposeful physical activity (Figure 1). Viewing the activity as a pact will likely 

hold the owner accountable and increase dedication to the act. An increase in dedication to physical activity might improve fitness levels and 

decrease the chance for musculoskeletal injuries during a military member’s required unit physical training 

sessions That being said, small goals 

Figure 1. Army Medicine fully supports integrating family pets into the Triad. This 

poster depicts an owner engaged in purposeful activity with her dog Bella. Poster 

courtesy of the US Army Public Health 

Center.
102 http://www.cs.amedd.army.mil/amedd_journal.aspx

should be set based on the size, stamina, and health of 

the dog and owner. For instance, a goal for those with 

small breed dogs may be to walk for a certain amount 

of time. A goal for larger, more athletic breed dogs may 

be to walk, or run, a certain distance. Time and distance 

should increase gradually based on the condition of both 

participants; a rigorous program should not be attempted for dogs or owners who are not properly conditioned. 

Obtaining the benefits of purposeful activity from a 

dog is also not limited to those that own dogs. Military 

members and their families have alternate opportunities 

available to them. In addition to simply “borrowing” a 

dog from a friend or family member, many animal shelters operated by local Humane Society chapters (www.

humanesociety.org) have dog walking/running programs designed to socialize, condition, and increase the 

adoptability of shelter dogs.

Improve Nutrition: Animal-Assisted Health

Physical activity and nutrition go hand in hand. Recommendations from the medical and public health community tend to focus on the combination of diet and exercise when addressing avenues to overall health. The 

reason for this focus has become increasingly evident in 

the past several decades as obesity rates have elevated to 

epidemic levels in the United States.49 In fact, the issue 

has become of such concern that national health organizations, like Trust for America’s Health, have sponsored on-line searchable databases that show the state 

by state effect of obesity (www.stateofobesity.org). Unsurprisingly, the Centers for Disease Control and Prevention recognizes the strong link between the components of obesity, unhealthy diet and physical inactivity, 

and chronic diseases like type 2 diabetes, hypertension, 

heart disease, stroke, and some cancers.50

It may seem counterintuitive in a physically demanding 

career, but military service members are not immune to 

the national overweight and obesity epidemic. A 2014 

report revealed that obesity rates among active duty service members rose 61% between 2002 and 2011, and that 

12% of the active duty force is currently obese.51 The 

tendency towards excessive weight gain and obesity is 

also uncommonly high in military family members.52

With physical activity and exercise reported to be higher 

in military families, as previously mentioned, poor nutrition, especially overeating, likely plays a much larger 

role in the epidemic.53,54

Unfortunately, pet obesity is likewise at epidemic levels 

in the United States. An annual survey on the issue recently indicated that almost 60% of the nation’s 95.6 million cats and over 60% of the nation’s 85.3 million dogs 

are overweight or obese.55 The survey further points 

out that pets, like their owners, suffer from some of the 

same chronic diseases related to unhealthy weight gain. 

The issue of pet obesity is also big enough to warrant a 

website dedicated to obesity awareness and prevention, 

www.petobesityprevention.org. Research into the trend 

tends to emphasize the large role that poor nutrition 

plays in the problem. Most in the veterinary community 

believe that pets are also eating too much. A groundbreaking paired feeding study from the Purina Pet Care 

Center helped to solidify this concept in 2002.56 The trial enlisted 48 Labrador retriever puppies from 7 litters. 

The puppies were paired within their litters according 

to gender and body weight; were randomly assigned to 

either a control group (fed ad libitum during daily feedings) or a lean fed group (fed 75% of the amount eaten by 

the littermates); and were weighed and had body condition assessed at consistent intervals. Incredibly, Kealy 

et al found that the overfed dog group not only died significantly sooner, 1.8 years, when compared to the lean 

group, they also required treatment for chronic conditions 2.1 years earlier than the lean fed group.

There appears to be some common ground to make mutually beneficial lifestyle changes given the connection 

between poor nutrition and human and pet weight gain. 

Improving nutrition does not require drastic changes. As 

the Triad guidance suggests, small changes can produce 

recognizable results. That being said, the most effective 

change may be for pet owners to follow the guidance that 

is given to their pets when an intervention for improved 

nutrition is prescribed by their veterinarian: choose high 

quality food, feed only to caloric needs, feed more than 

once a day, and decrease unhealthy snacking.

Successful dual nutrition plans have been explored 

through research. One such success was outlined in a 

program that paired 36 pairs of overweight or obese 

people with an obese pet to a control group (overweight 

or obese people with no pet).57 Over the course of a year 

participants in the program received dietary, as well as 

physical activity, counseling and dogs were fed a calorie 

restricted diet. By study’s end, owners with pets tended 

to stick with the program longer and had higher mean 

weight loss (5.2% compared to 4.7%, though this was 

not considered statistically significant). The dogs also 

greatly benefitted from engaging with their owners in 

the program as they had statistically significant weight 

loss and improvement in overall body condition.

Mutually beneficial nutrition improvement can be implemented within the family. The author believes that 

this can occur quite easily by following the guidance 

mentioned above. Choosing high quality food does 

not mean choosing the most expensive food; it means 

Animal-Assisted Health and the Performance Triad
October – December 2016 103

The Army Medical Department Journal

checking labels to ensure that ingredients meet the suggested nutrient profile for the individual pet or owner. 

The US Food and Drug Administration requires that nutritional profiles be present on all packaged food, including pet food, and that ingredients be listed in descending 

amounts.58 Feeding, or eating, only to individual caloric 

needs addresses the tendency to overfeed, or overeat. 

The American Animal Hospital Association also recommends that pet owners feed at least 2 meals a day 

as opposed to one large meal.59 This matches recommendations published in the US Department of Health 

and Human Services Dietary Guidelines for Americans

2015-2020 against eating large calorically dense meals.

60

These dietary guidelines urge replacing unhealthy 

snacks with healthier options as well. A particular parallel can be drawn between improving human and pet nutrition in regards to snacks. For instance, it is common 

practice for veterinarians to recommend that clients replace commercially produced animal treats with 

fresh or frozen vegetables to improve 

nutrition in overweight pets (Figure 

2).61 Therefore, having a bigger supply of vegetables in the house could 

actually help improve nutrition in the 

entire family.

Get Quality Sleep: 

Animal-Assisted Health

Of all the Triad goals, getting consistent, quality sleep is often the 

most difficult one to realize. Public 

health professionals agree as insufficient sleep is now considered a public health problem.62 One national 

survey indicated that nearly 30% of 

adults averaged less than 6 hours of 

sleep a night.63 Lack of sleep naturally disrupts the performance of 

both simple and complex tasks. As 

expected, those who do not get adequate sleep report that they have trouble concentrating 

on/remembering things, taking care of financial affairs, 

performing at work, and often nod off while driving.62

Military members are quite susceptible to sleep deprivation and its consequences. In fact, those who serve 

are at exceptional risk for poor quality sleep given the 

frequent high demands expected of the job. In their paper on lack of sleep as an emerging issue in the military, 

Brown et al 64 postulate that the problem represents a 

multifactorial relationship between personal health, 

habits, and lifestyle contrasting with the emotional and 

physical stress of the work. This is reflected in data 

from the large cohort of military members participating 

in the Millennium Cohort study* as poor sleep quality 

was significantly associated with lower rated self-health, 

more lost work days, and more healthcare utilization.65

It is not just lack of sleep that is affecting military members either. The prevalence of those suffering from sleep 

disorders in the military is also on the rise.66 It stands 

to reason that military family members also share this 

sleepless burden as they experience the unique stress of 

military life alongside the military member.

Companion animals, on the other hand, rarely have trouble sleeping. Dogs usually spend about 50% of their day 

sleeping and 30% lying around while 

awake.67 Cats are even more prodigious sleepers as they are known to 

sleep as much as 15-20 hours a day.68

Given this information, it is not hard 

to see why both animals are immortalized in idioms such as “let a 

sleeping dog lie” and “catnap.” Nevertheless, anyone who has slept with 

a pet on their bed knows that there 

are difficulties inherent in the habit. 

Like humans, pets typically do not 

appreciate movement while sleeping 

and often reposition. This practice 

leads to sleep disturbances for all involved. Cats can be particularly poor 

bed mates due to their propensity for 

sleeping on top of their owners, and 

further complicate sleeping as crepuscular creatures (most active at 

dusk and dawn).68

Despite these potential sleep disturbing behaviors, a national survey reports that 45% of dogs and 62% of cats still share the 

pet owner’s bed.69 The common assumption is that cosleeping with pets is ultimately a bad way to get quality 

sleep. There is research to support this statement; however, new research indicates that co-sleeping may actually be beneficial. Krahn et al 70 addressed the assumption in their 2015 report from the Center for Sleep Medicine in Arizona. A comprehensive sleep questionnaire, 

which probed into pets in the bedroom, was given to 150 

Figure 2. Army Medicine fully supports 

integrating family pets into the Triad. This 

poster depicts an owner engaging in mutually beneficial nutrition practices with 

her dog Gracie. Poster courtesy of the US 

Army Public Health Center.

*The Millennium Cohort Study is an ongoing longitudinal cohort study headquartered at the Naval Health Research Center in San Diego, 

California and designed to evaluate any long-term health effects of military service, including deployments. It is the largest populationbased prospective health project in US military history, currently collecting data on over 200,000 enrolled participants. Information 

available at: http://millenniumcohort.org/.
104 http://www.cs.amedd.army.mil/amedd_journal.aspx

consecutive patients. Of the 46 participants that co-slept with pets, only 

20% described their sleep as disruptive whereas over 40% perceived the 

security, relaxation, and companionship provided by their pets to be 

an aid in achieving quality sleep.70

Rose et al 71 also tout the benefits of 

co-sleeping, principally as a therapy 

for those prone to sleep disorders, in 

their 2015 Sleep Review article. They 

posit that the prescription of a cosleeping pet or service animal may 

be a valuable, and underappreciated, 

accessory therapy for subpopulations, 

like veterans, who have difficulty obtaining quality sleep.

Medical professionals who work in 

the field of sleep science are beginning to understand that assumptions 

linking co-sleeping and sleep disturbance are not necessarily evidencebased.71 Pets can actually be a very positive influence on 

military members and their families seeking to achieve 

the Triad goal of obtaining quality sleep (Figure 3). Another, more novel, area where they might be beneficial 

to pet owner’s overall sleep is through napping. Dogs 

and cats both spend the majority of their daytime sleep 

in a light, nap-like, state.67,68 This allows them to be 

roused easily and explains why they rarely miss a ringing doorbell or rustling treat bag when dozing. There 

is evidence that taking this cue to nap might be a good 

idea. Researchers have found that short naps (less than 

30 minutes) can promote waking function after normal 

sleep and can even counteract decreased alertness and 

performance in the sleep deprived.72 That being said, if 

co-sleeping helps some military families get a restful 

night’s sleep, then “co-napping” might also prove valuable. This does not mean that pet owners should nap as 

often as their pets do because too much sleep can be just 

as harmful as too little.73 It may mean, though, that pets 

play a part in a recharging 30 minute weekend nap on 

the couch. They may even help prevent oversleeping by 

acting as an adjunct alarm clock that springs to life at 

the opening of a refrigerator door.

Conclusion

Companion animals are commonplace in military families. Most choose to share their home because of the 

companionship and perceived calming effect that pets 

provide through the human-animal bond.74 Beck et al 

describe that this unique connection is the impetus for 

the quick transition from pet to family member:

All indications are that companion 

animals play a role of a family member, often a member with the most 

desirable traits...For some, pets increase the opportunities to meet people, while for others pets permit them 

to be alone without being lonely.75

In addition to this role, pet owners 

consistently report that they believe 

that pets are good for the health of 

the family.76 Those statements are 

backed by the scientific community. 

As referenced above, pets have been 

shown to provide well-being promoting social support and stress reduction, as well as tools to improve long 

term cardiovascular and immunological health.

Pets can also provide valuable animal-assisted health for those seeking to improve health and fitness 

through implementation of the Performance Triad. They can be a stimulus for their owners 

to perform purposeful physical activity which has been 

shown to help lowly motivated individuals stick to an 

exercise plan. Pet owners can team up with their pets 

and adopt mutually beneficial nutrition plans that can 

help both maintain a healthy weight. Finally, pet owners 

can explore the benefits of co-sleeping and co-napping 

with their pets which may be a useful aid to achieve better quality sleep. It should be noted that animal-assisted 

health may not be the best option for those who are indifferent to animals.77,78 However, for those that value 

the human-animal bond, pets should be considered a 

potential asset on the path to better health.

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Author

MAJ French is the Public Health Instructor for the First 

Year Graduate Veterinary Education Program, Joint 

Base Lewis-McChord, Washington. He is also one of the 

Army Veterinary Corps subject matter experts on the 

human-animal bond.
108 http://www.cs.amedd.army.mil/amedd_journal.aspx

Real life scenarios? Yes. Two of the authors experienced 

these situations and, at the time, really did not have answers to the questions that were being asked: Was the 

inpatient’s dog a service animal? Did the school have to 

accept the child’s service animal in the classroom? If so, 

what were the patient’s rights, and what were the facilities rights and duties under the law? Does the Americans 

with Disabilities Act (ADA) (42 USC chptr 126) control 

these scenarios, or can local policy supersede federal 

and state laws? Was the little dog in the basket a therapy 

or activity animal, or simply a companion, social animal, 

or a pet? Depending on its status, what legal restrictions 

or options were available to the administrative staff at 

these facilities? These questions are certainly not unique 

and, most likely, similar questions are asked every day 

at DoD facilities around the world as canine-assisted 

therapy in military medicine has become more prevalent 

over the years. In their 2012 article, Mills and Yeager 1

provided definitions of animals used in healthcare setting. This paper expands upon their article in light of recent DoD and Army policy on the issue of service dogs 

and the use of animals in the healthcare setting.

Review of the Americans With Disabilities Act

The Mills and Yeager article focuses on definitions. Definitions are key when determining whether an animal 

fits within the protection of the ADA. Knowing definitions would have truly helped in the given scenarios, but, 

even with such definitions, the military has never been 

covered by the ADA in terms of service animals. Surprised? The requirements in Title II of the ADA were 

only applicable to “public entities,” and federal government agencies such as the DoD and Department of 

Veterans Affairs (VA) were never included in the ADA 

definition of a public entity under 42 USC 12131(1).

A short overview of the structure of the ADA is necessary so that the reader can appreciate the difficulty, in 

general, involved in determining an animal’s status as 

a service animal. First, the ADA is divided into 5 titles:

Title I addresses Employment and Equal Employment 

Opportunity for Individuals with Disabilities. Very often, managers see this part of the law in action during 

employment-related actions and enforcement through 

the US Equal Employment Opportunity Commission.

Title II deals with state and local government and affects 

nondiscrimination on the basis of disability in state and 

local government services. This title basically spells out 

how administrative processes are managed within state 

and local governments and their related organizations, 

Service Animals: A New Legal Dimension

 Within the US Military

Joseph B. Topinka, JD, MHA, MBA, LLM

Jack Nichols, JD

Matthew Brooks, PhD, MPH

Scenario 1:

An inpatient at a major military treatment facility (MTF) has a dog with him. No one on the ward wants to ask 

him whether the dog is a service animal. Instead, everyone on the ward takes turns walking the dog outside the 

facility until later in the day, when the charge nurse says enough. The nurse calls the command judge advocate 

of the medical center to confront the patient about his dog and where it will stay overnight. “This is a legal 

issue” states the charge nurse to the lawyer.

Scenario 2:

Months later, the same lawyer (Scenario 1 above) is having lunch in the MTF dining facility when he sees a 

group of people huddled together near one of the dining tables. He approaches the table, where he sees a family with a basket on the table that contains a little dog that everyone thinks is adorable. Another legal issue or 

a public health concern?

Scenario 3:

A Department of Defense dependent with a service dog arrives at her school located on a military installation. She is wheelchair bound, and the dog has been trained to assist her with many tasks, including pulling 

her chair and opening doors. She has an identification card showing that she and the dog have been certified 

as a service animal team, and it includes the applicable federal and state statutes. What does the principal do?
October – December 2016 109

The Army Medical Department Journal

agencies, etc. It is regulated and enforced by the Department of Justice.

Title III deals with public accommodations and affects 

nondiscrimination on the basis of disability by public 

accommodations and in commercial facilities. This title 

does not deal with government entities at all, but it is also 

regulated and enforced by the Department of Justice.

Title IV addresses telecommunications and requires 

telephone and internet companies to provide individuals 

with hearing and speech disabilities with the ability to 

communicate through these media. It is regulated and 

enforced by the Federal Communications Commission.

Title V is a miscellaneous provisions section that contains a variety of provisions on the ADA as a whole, and 

it is more administrative in nature.

If the federal government were to fit under any title, the 

closest would likely be Title II, but its definitions only 

cover “any state or local government.” To compound 

any misunderstanding, there is no definition of service 

animal within the ADA statute itself.

Definitions of service animals are found in the implementing regulations of the ADA in Title 28 in the Code 

of Federal Regulations (CFR) which are written by the 

Department of Justice. Title II is implemented through 

28 CFR 35. Part 35, Section 104, which provides the following definition:

Service animal means any dog that is individually 

trained to do work or perform tasks for the benefit of 

an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. 

Other species of animals, whether wild or domestic, 

trained or untrained, are not service animals for the purposes of this definition. The work or tasks performed by 

a service animal must be directly related to the individual’s disability. Examples of work or tasks include, but 

are not limited to, assisting individuals who are blind or 

have low vision with navigation and other tasks, alerting 

individuals who are deaf or hard of hearing to the presence of people or sounds, providing nonviolent protection or rescue work, pulling a wheelchair, assisting an 

individual during a seizure, alerting individuals to the 

presence of allergens, retrieving items such as medicine 

or the telephone, providing physical support and assistance with balance and stability to individuals with mobility disabilities, and helping persons with psychiatric 

and neurological disabilities by preventing or interrupting impulsive or destructive behaviors. The crime deterrent effects of an animal’s presence and the provision of 

emotional support, well-being, comfort, or companionship do not constitute work or tasks for the purposes of 

this definition.

This definition is the same within Title III at Part 36, 

Section 104. In addition, both titles also address miniature horses in Sections 136 and 302 respectively:

A public entity shall make reasonable modifications in 

policies, practices, or procedures to permit the use of a 

miniature horse by an individual with a disability if the 

miniature horse has been individually trained to do work 

or perform tasks for the benefit of the individual with a 

disability.

This last definition is the only exception to the standard 

rule that service animals are dogs.

Reaction Within the Federal Government

Since the ADA does not apply to the federal government, 

and its definition of service animal is very limited, what 

have executive departments such as the VA and DoD 

done for Veterans and service members? How have they 

been able to get around their limitations but at the same 

time create policy that is within the spirit of the ADA in 

regard to service animals?

Department of Veterans Affairs

The VA was able to take a more direct approach through 

its implementing regulations under Title 38 through the 

support of Congress in its amendment of 38 USC 1714 

to authorize the VA to provide service dogs for Veterans with other disabilities. The statute was originally 

designed to provide dogs trained to aid the blind and 

Hero, a trained service dog, providing comfort and emotional support (in the role of animal-assisted activities) at the Occupational 

Therapy Clinic, Walter Reed Army Medical Center. Photo courtesy 

of Mills and Yeager.1
110 http://www.cs.amedd.army.mil/amedd_journal.aspx

hearing impaired. The amendment “broadened and 

clarifie[d] current benefits to Veterans with guide dogs...

and establish[ed] new benefits related to service dogs (77 

Federal Register 172 (2012)). Critical to the VA’s ability 

to adopt a regulation was the intent of Congress through 

the amendment. The VA did not implement a rule with a 

definition consistent with 28 CFR 36.104 because it was 

simply not the intent of Congress. The rule adopted (Title 38, Part 17, Section 148 (a)) was consistent with the 

administration of benefits to Veterans with service dogs:

Service dogs are guide or service dogs prescribed for a 

disabled veteran under this section.

The VA’s definition was simple yet broad, but also directly connected to the rest of Section 138 which goes 

into more detail about clinical requirements, service dog 

recognition, authorized benefits, and maintaining the 

ability to function as a service dog. One the one hand, 

the VA policy was in synch with the ADA in that it pertained directly to dogs. On the other hand, the policy 

had a specific veteran benefit focus and not Title II’s 

focus on access to public facilities by individuals with 

disabilities.

Department of Defense

The DoD approach was neither direct nor simple. In 

fact, the DoD’s approach was a patchwork effort mostly 

led by the Army Medical Department (AMEDD). In 

2012, Watkins 2

 discussed policy initiatives for canines 

in Army medicine. Her article, along with that of Mills 

and Yeager,1

 provided a summary of what the AMEDD 

had done in terms of filling in the gap within the DoD 

pertaining to the use of canines and the use of animals 

in general within the healthcare setting. For example, 

Policy Memo 12-0053

 issued by the Army Medical 

Command (MEDCOM) in January 2012 was a comprehensive effort by the AMEDD to cover definitions 

and provide clear guidance to leaders in Army medicine 

concerning the use of animals. It relied on past policy, 

past practice, research, and adopting language of the 

ADA as stated in Policy Memo 12-005:

...it is the [MEDCOM] commander’s intent that MEDCOM facilities abide by these [ADA] provisions to as 

great a degree as is practicable and when such adherence 

does not hamper readiness.3(p2)

It was the type of guidance that would have been very 

useful for those of us who experienced the aforementioned scenarios (and other similar situations) at the 

time. There was simply no guidance within the military, 

and we had to piece together some advice based on a 

loose reading of the ADA along with simple common 

sense, which ultimately became the basis for the MEDCOM commander’s policies. However, the MEDCOM 

guidance was not replicated within the other services, 

nor adopted by the entire US Army or DoD.

Two developments have occurred since the articles by 

Mills and Yeager 1

 and Watkins 2 were published:

1. On January 28, 2013, Secretary of the Army John 

McHugh signed Army Directive 2013-014

 which defined 

service dogs for the first time at the military secretarial 

level. The directive took some of the best aspects of the 

ADA and the OTSG/MEDCOM policy and made them 

official policy, Army-wide:

a. Service Dogs. A service dog is a dog individually 

trained to do work or perform specific task for the benefit 

of an individual with a disability. Service dogs include 

guide dogs that assist individuals who are blind or have 

low vision with navigation and other tasks.4(p1)

2. On January 7, 2016, Acting Under Secretary of Defense for Personnel and Readiness Brad Carson, signed 

Department of Defense Instruction 1300.27, Guidance 

on the Use of Service Dogs by Service Members. This 

instruction’s significance is the departmental level effort 

to standardize a definition of service dog and the use of 

service dogs across the entire organization, much as has 

been done by the VA. In addition, it refers to the definition of service dogs from both Title 28, Section 35.136, 

and Title 38, Section 17.148, in its overall purpose in 

establishing policy, assigning responsibility, and providing procedures department-wide. However, we believe 

that the definitions, including that of a service dog, fall 

short of providing the same measure of comprehensive 

guidance that OTSG/MEDCOM Policy Memo 12-0053

provides in the medical setting. Its real focus is on the 

acquisition of service dogs for service members, particularly the standardization of that narrow issue. The 

Raliegh, a facility animal, providing counterbalance during a 

physical therapy sesson (in the role of animal-assisted therapy) 

at the Military Advanced Training Center, Walter Reed Army Medical Center. Photo courtesy of Mills and Yeager.1

Service Animals: A New Legal Dimension Within the US Military
October – December 2016 111

The Army Medical Department Journal

DoD instruction could have gone farther in providing 

meaningful standardization to all the services, both inside and outside of the medical setting. As written, it 

leaves a substantial amount of authority and discretion 

in developing and implementing policies regarding all 

animals, including service dogs, to the secretaries of 

the military departments. As a result, many gaps in the 

policy remain across DoD.

Unfinished Business

We believe that more should be done in developing and 

implementing service policies pertaining to service animals. Title II and Title III of the ADA limit their definition of service animals to dogs and, in some instances, 

miniature horses. But what about all the other animals 

that are defined by Mills and Yeager 1

 or in OTSG/MEDCOM Policy Memo 12-005? 3

 If definitions are truly key 

when determining whether an animal fits within some 

type of protection, why have more policies not been 

published or developed, not only in the medical setting 

but at the installation level as well? Even if the services 

create individual policies to address their service, the 

implementation of the “joint-base” concept prevents one 

military service from implementing its specific policy 

on an installation controlled by another service. Should 

Congress be the ultimate deciding authority on this topic as it was for the VA? These questions must necessarily 

be addressed in the future.

References

1. Mills JT, Yeager AF. Definitions of animals used 

in healthcare settings. US Army Med Dep J. AprilJune 2012:12-17.

2. Watkins KL. Policy initiatives for the use of canines in Army medicine. US Army Med Dep J. 

April-June 2012:8-11.

3. OTSG/MEDCOM Policy Memo 12-005: Overarching Guidance on the Use of Animals in the Healthcare Setting (Service Animals, Animals Assisted 

Therapies, and Animal Assisted Activities). Fort 

Sam Houston, Texas: US Army Medical Command; January 30, 2012. Available at: https://www.

army.mil/e2/c/downloads/250935.pdf. Accessed 

July 28, 2016.

4. Army Directive 2013-01 (Guidance on the Acquisition and Use of Service Dogs by Soldiers). Washington, DC: US Department of the Army; January 

28, 2013. Available at: http://www.apd.army.mil/

Search/ePubsSearch/ePubsSearchDownloadPage.

aspx?docID=0902c85180010d37. Accessed July 29, 

2016.

5. Department of Defense Instruction 1300.27: Guidance on the Use of Service Dogs by Service Members. Washington, DC: US Department of Defense; 

January 7, 2016. Available at: http://dtic.mil/whs/

directives/corres/pdf/130027p.pdf. Accessed July 

29, 2016.

Authors

Mr Topinka is an assistant professor in the School of 

Health Administration at Texas State University where 

he has taught courses in various topics including employment law and public health.

Mr Nichols is a government attorney at Headquarters, US 

Army Medical Command whose interest in service dogs 

began when nonaccredited “service dog providers” began providing untrained animals to Wounded Warriors.

Dr Brooks is Director of the School of Health Administration at Texas State University. He is also an Associate 

Professor in the School and has taught courses in various 

topics including healthcare strategic management, policy development, healthcare organization and delivery, 

management of health information systems, and medical 

informatics.

Photo courtesy of COL (Ret) Elspeth Ritchie, MC, USA
112 http://www.cs.amedd.army.mil/amedd_journal.aspx

There wasn’t any bickering. There wasn’t time. Everybody 

did their job. We’re trained for emergencies. Disasters.

Lt. Gelane Barron, ANC; Tripler Hospital Emergency Room1

Much has been written about the military events of December 7, 1971; however, little has been documented 

about the Army nurses’ work and experience in Pearl 

Harbor, Hawaii. This paper will describe the role and 

experience of six Army nurses who were caring for patients at Hickam, Tripler, and Schofield Hospitals on December 7, 1941.

During World War I, the number of nurses in the Army 

Nurse Corps (ANC) grew from 403 nurses on active 

duty to 21,480 total nurses serving in the “Great War.” 2

This number dramatically decreased during peacetime 

and the Great Depression which crippled the American 

economy. At the end of 1941, fewer than 1,000 ANC 

nurses were on active duty.3

 The few military nurses 

who were on bases in the United States in the 1940s kept 

busy by treating communicable diseases and orthopedic 

injuries from sport or training exercises.4

Several young and promising ANC nurses were stationed at Walter Reed Hospital, performing their regular 

duties as well as helping to recruit other nurses.5

 In early 

1941, a notice appeared asking for volunteers to serve 

abroad in the Philippines or Hawaii. Lt. Pauline Girard, 

Lt. Monica Conter, and Lt. Kathleen Coberly were looking for opportunities to travel overseas, and volunteered 

to serve. That summer, they traveled together by train 

from Washington, DC to San Francisco to await passage to Hawaii on the USS Mariposa.5-7 They arrived in 

Hawaii on July 11, 1941.6

Those nurses fortunate enough to be stationed in Hawaii were enjoying the tropical lifestyle of shorter shifts, 

days at the beach, and beautiful parties at beachside hotels. Many other Navy and Army nurses arrived in Hawaii throughout 1941 in anticipation of foreign threats 

in the Pacific. As the war in Europe intensified, more 

young women became part of the ANC; however, numbers were not yet high enough to meet the potential need 

should the United States become involved in the war. By 

Grace Under Fire: The Army Nurses of

 Pearl Harbor, 1941

Gwyneth R. Milbrath, RN, MSN, MPH*

Abstract

Objective: Much has been written about the military events of December 7, 1941; however, little has been documented 

about the nurses’ work and experience at Pearl Harbor, Hawaii. The aerial assault on Pearl Harbor was the first time in US 

history that Army nurses had been on the front line of battle. Nurses quickly triaged and stabilized those who could be 

saved, and provided compassion and comfort to those who were dying, in an environment where the nurses were unsure 

of their own survival.

Methods: Traditional historical methods and a social history framework were used in this investigation. Primary sources included oral histories from the US Army Medical Department Center of History and Heritage and the State of Hawaii’s website, Hawaii Aviation. Secondary sources included published books, newspaper articles, military websites, and history texts.

Results: Due to the limited bed capacity, Hickam Field Hospital converted to an evacuation hospital. Nurses, physicians, 

and medical corpsman triaged, stabilized, and transported those likely to survive, while staging the dead behind the 

building. The emergency room at Tripler Hospital was quickly flooded with patients from the battlefield, but the staff was 

able to sort patients appropriately to the wards, to the operating room, or provide comfort care as they died. At Schofield 

Hospital, collaboration between tireless doctors, nurses, and corpsmen was key to providing life-saving surgery and care.

2015

Spurgeon Neel Award Winner

The Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual Award 

competition for the best original article that best exemplifies the history, legacy, and tradition of 

the US Army Medical Department. The following article by Gwyneth Milbrath was selected as 

the best submission of the 2015 competition.

*Ms Milbrath, an Instructor of Nursing at the University of Northern Colorado, Greeley, Colorado, is currently a doctoral student 

at the University of Virginia School of Nursing, Charlottesville, Virginia.
October – December 2016 113

The Army Medical Department Journal

December 1941, there were 82 Army nurses stationed in 

Hawaii serving at three Army medical facilities: Tripler 

Hospital, Schofield Station Hospital, and Hickam Field 

Hospital.3

 The evening of December 6th, there was an 

elaborate party at the Officer’s Club that many of the 

nurses attended with their dates.6-8 Lt. Conter thought 

the view of the light from the battleships reflecting on 

the water was “the most beautiful sight she’d seen.” 5

Disaster Strikes Oahu

At 6 am on the morning of December 7, 1941, six 

Japanese carriers positioned 200 miles north of Oahu 

launched the first wave of 181 planes set to destroy Pearl 

Harbor.9

 Although there were some early reports of abnormal activity the morning of December 7, the warning signs were unheeded and the US military forces at 

Pearl Harbor were taken by surprise when the Japanese 

attacked. The Japanese arrived flying approximately 

150 feet over Pearl Harbor, guns blazing, a few minutes 

before 8 am that Sunday morning.9

Lt. Kathryn Doody lay in bed at the nurses’ quarters 

in Fort Shafter, Hawaii, on the morning of December 7, 

attempting to get some extra sleep on her day off. The 

noise was so loud; she thought that one of the volcanoes 

was erupting. Fort Shafter is located in Honolulu, Hawaii, 

about 5.5 miles from Pearl Harbor, and was home to Tripler Army Hospital.10 Meanwhile, Lt. Gelane Barron was 

already walking to work to begin her shift in the Tripler 

Emergency Room. Barron noticed the planes and smoke, 

but assumed, like many others, that the Army and Navy 

pilots were having maneuvers, or the US B-17 bomber 

planes scheduled to arrive that day were landing.1

North of Tripler in the mountains of Oahu was Wheeler 

Army Air Field, and Schofield Barracks, home to Schofield Station Hospital. Lt. Mildred Irene Clark, also off 

duty that morning, was sleeping in the barracks at Schofield. The sound of the planes flying directly overhead 

was so loud it shook the barracks. She tried to go back to 

sleep, but realizing something was wrong, she called the 

operating room (OR) at Schofield to see if they were in 

need of her services. Lt. Clark was told she and all other 

surgical nurses were to come to the OR immediately. 

She was out the door in two minutes, running the elevenblock distance from the barracks to the hospital. “I saw 

what looked like big oranges on the planes and I could 

see two men. I don’t remember being afraid...they were 

so close that I could hear them talking on their phones...

and they were right down over the hospital.” 8

Lt. Girard was already on duty on the wards at Schofield and had just settled into her daily routine when she 

heard something crash near the building. She joined 

the patients out on the porch and could see the low flying planes. “The sergeant standing next to [her] said, 

‘Ma’am, can’t you see the rising sun on those planes?’...

You could see the Japanese bowing low and [Schofield] 

had a big red cross on the building but they were machine gun firing so I shoved everybody into the ward.” 7

The Japanese were attacking the military strongholds in 

Oahu, including Pearl Harbor, Wheeler Air Base, and 

Hickam Air Base, dropping half-ton bombs and raining 

down machine gun fire.11

Hickam hospital was a brand new, 30-bed facility located adjacent to Pearl Harbor on Hickam Army Air Base. 

Lt. Monica Conter was one of two nurses on duty at this 

small facility when the Japanese suddenly attacked the 

air base. As she was evacuating patients in the elevator from the third floor to the first floor, a bomb hit the 

Hickam power plant and all the clocks stopped at 7:55

am.

5

 Both Hickam Field and Wheeler Army Field, along 

with Pearl Harbor, were priority targets for the Japanese. Their aim was to prevent any US fighter planes 

from defending against the Japanese attack force. Had 

any US bomber, fighter, or patrol planes been airborne, 

the primary Japanese aim of destroying the Pacific fleet 

could have been severely compromised. The Japanese 

attacked with two strikes about half an hour apart. Both 

Hickam and Wheeler Air Base suffered heavy damages 

and casualties during both strikes.11

Once military leaders realized what was happening, 

Tripler, Schofield, and Hickam began to prepare for the 

incoming casualties. All off-duty staff were called in 

from their quarters, patients were discharged or moved 

to make room for the incoming wounded, and additional bed spaces were created wherever there was space. 

When Lt. Barron walked into the ED at Tripler Hospital, 

it was already full of patients on litters needing care.1

Schofield Hospital also had ambulances waiting to unload patients with litters of patients lining the halls outside the operating rooms.8

Years later, these nurses would reflect on their level of 

preparedness for the bombings that occurred that morning. Many nurses were relatively new to military nursing and had never been stationed outside of the United 

States. Some nurses felt well prepared to handle the challenges of that day, and others managed to adapt quickly 

to the changing situation and provide high-quality care 

to the injured soldiers. There was no formal mass casualty training, gas mask training, or basic military training of any sort for the nurses stationed at Pearl Harbor 

prior to 1942.1,10 Most nurses arrived at their duty station, 

were given basic lessons of Army etiquette and a couple 

hours of orientation to the ward, and were put to work.1
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The medical and surgical nurses at Tripler and Schofield 

were not trained for a mass casualty scenario, however, 

the hospitals were able to create more beds and had a 

sufficient stockpile of supplies to meet the needs of the 

patients.8,10 Field medical officers commanded a field 

force unit, and each unit had an ambulance assigned 

that was able to quickly transport patients from the front 

lines to the hospitals.8

 Despite a lack of training in mass 

casualty or disaster plans, the Tripler emergency room 

was able to efficiently triage and stabilize the hundreds 

of patients arriving from Hickam and Pearl Harbor. “Everybody knew their job. Everybody was trained for warfare and I think we worked very well as a group. There 

was no panic or anything.” 10

Hickam Field Hospital

The situation at Hickam Hospital was much more chaotic 

than Tripler Hospital due to drastic differences in staffing, resources, and capacity. The Hickam nurses, corpsmen, and physicians were frantically trying to handle the 

hundreds of casualties on their front lawn with only the 

resources and space to care for 30 patients. Hickam Hospital had only been open for three weeks, and the few 

nurses trained to staff the hospital were still unfamiliar 

with the facility. Many of the beds were still missing a 

mattress, and only the third floor was set up for inpatient 

care. All patients were evacuated to the first floor where 

they believed they would be safer from the bombings.5

After the first wave of bombing ended, the casualties 

began to pour into Hickam hospital. The barracks had 

been heavily bombed and collapsed during the attack, 

killing and wounding the many soldiers that were still 

in their rooms. Patients from the barracks had terrible 

crush injuries and wounds contaminated with the dust 

and debris from the building collapse.5

 Three additional 

nurses, including Chief nurse Annie Fox, arrived to assist the two nurses who were struggling to manage the 

unimaginable influx of patients. The wounded soldiers 

and civilians arrived at Hickam in ambulances, CocaCola trucks, laundry trucks, private vehicles, and anything else that was available.1,6 Patients were triaged 

as they arrived at the hospital; those still living were 

placed on the ground along the porch, and the dead and 

mortally wounded were placed behind the hospital. The 

nurses began stabilizing and comforting the hundreds of 

patients at their door as quickly as they could.5

“We would just go down that porch giving [morphine] 

shots and trying to stop the hemorrhaging and the pain 

on that outdoor porch with people lined up. We would 

give it just as fast as we could... It was a thing to do 

in an emergency, which is an understatement. Just going down the porch giving those 10 shots with a 10cc 

syringe... We went in to fill up and came back out where 

we left off and gave more...that’s how I reacted and everybody else was doing it. That was the only thing we 

knew to do in the middle of all of this. We hoped we 

were saving their lives, keeping them from pain, and 

maybe stopping some of the hemorrhaging.” 5

In total, 139 soldiers were killed and 303 were wounded at Hickam Air Base, and the vast majority of these 

casualties would have stopped for treatment at Hickam 

Hospital.12 Anticipating that Hickam would become 

completely saturated with severely wounded soldiers, 

Major Frank H. Lane, commander of Hickam Field Hospital, wisely decided to convert Hickam into an evacuation hospital, keeping only the “walking wounded,” 

and transferring all other cases to Tripler or the civilian 

Queen’s Hospital in Honolulu.6,13

Tripler Hospital

At Tripler Hospital, the staff in the emergency room 

quickly triaged, stabilized, and admitted all the Soldiers 

coming from Hickam Field as well as some Navy Sailors from Pearl Harbor. Those that were dead or mortally 

wounded were sent to a temporary morgue located behind the hospital. Patients were then prioritized based 

on who needed immediate surgery that day, those who 

could wait until a later date, and those who could go 

directly to the wards. The emergency nurses continued 

to give the patients injections of morphine and tetanus 

in a similar fashion as those at Hickam. They marked 

their foreheads with an M or a T to document who had 

received these medications.1

Tetanus and other infections were a chief concern of 

those providing wound care; however, inside the war 

zone sterility was not always possible. Despite using 

the same needle on multiple patients, no infections were 

reported.1,5 All soldiers would have received a tetanus 

immunization prior to entering the combat zone, and 

those with injuries from shrapnel, bullets, or other metals were given a booster vaccine. There were no deaths 

due to tetanus reported in Pearl Harbor. The addition of 

sulfa drugs in wound care drastically decreased mortality rates from infection in World War II compared to 

World War I. Oral sulfa therapy was administered both 

pre- and postoperatively. Every soldier carried a packet 

of sulfa drug and was instructed to take it orally as soon 

as he was wounded.14

Despite the fear and uncertainty that most felt on December 7, 1941, medically trained and untrained people 

quickly arrived at Tripler to help manage the overwhelming number of casualties. Civilian volunteer nurses were 

automatically inducted into the ANC, and those off duty 

Grace Under Fire: The Army Nurses of Pearl Harbor, 1941
October – December 2016 115

The Army Medical Department Journal

reported immediately to help.1 Coincidently, there was 

a physicians’ convention in Honolulu that weekend, and 

the speaker for the morning of the bombing was delivering a lecture about war casualties. “...In the middle 

of this lecture, word went out to the auditorium where 

they were, all available doctors to report to Tripler Army 

Hospital...we got lots and lots of civilian doctors that 

day.” 10 Another surgeon had presented a new way to locate shrapnel, and was able to use this method on many 

of the injured soldiers.1

 A total of ten additional physicians and six additional surgeons reported to Tripler to 

assist with the many casualties.15

Many patients were received at Tripler with gaping 

wounds. Fragment wounds required immediate surgery 

and were sent to the operating room where Lt. Doody 

had just arrived and was preparing to assist as a circulating nurse in the OR.1,10 She scrubbed to prepare to enter 

the sterile operating room, she could see three patients 

sharing the operating room. Patients often could not be 

moved onto the operating tables, and their surgery was 

performed on the litter used to transport them into the 

hospital from the warzone.10

Schofield Station Hospital

The operating room at Schofield Station Hospital was 

just as busy as Tripler. Most of their patients had arrived 

from the nearby Wheeler Field Air Base, and had severe 

abdominal wounds and mangled arms and legs requiring amputation. ANC nurse Lt. Clark immediately began to prepare the most critical patients for surgery. As 

one of only two nurse anesthetists at Schofield that day, 

Lt. Clark could not manage all the preparation and intraoperative sedation alone. When she arrived, there were 

approximately 30 patients lined up along the hallway 

outside the OR for surgery. Volunteer physicians helped 

with anesthesia by giving IV anesthetics, spinal blocks, 

and administration of blood products; however, only 

those specially trained in anesthesia were able to give 

inhaled anesthetics. Lt. Clark described her overall experience that day as extremely efficient. Nurses and physicians worked together as a team with some physicians 

prepping patients for surgery while others operated. Lt. 

Clark used her nursing expertise to prepare her patients 

both physically and spiritually for surgery. In addition 

to providing important therapies, she spent time talking 

and praying with her patients. She wanted to meet any 

needs her patient may have had, not just medical needs.8

The medical knowledge at the time understood shock 

as failure of the peripheral vascular system resulting in 

inadequate circulation. This could be caused by loss of 

one to two quarts of blood; resulting in pallor, mental 

status changes, gasping respirations, increased heart 

rate, and a profound drop in blood pressure. Shock was 

prevented through controlling bleeding, immobilizing 

fractures to prevent further bleeding from movement, 

and warming the body with blankets and warm oral fluids. Pain control was also an important tenant of shock 

prevention. Pain was understood to worsen shock, so 

morphine was given not only to relieve pain, but also to 

improve a soldier’s chances of survival. Morphine was 

given intramuscularly in doses of a quarter to half grain, 

or 15-30 mg. If a Soldier were showing early signs of 

shock, he would be positioned with his legs above his 

head and given oral fluids immediately unless he needed 

an emergent operation. Solutions with 3%-5% glucose 

or 0.9% sodium chloride were given either subcutaneously or, preferably, intravenously. Intravenous (IV) 

fluids were preferred because glucose solutions could 

provide some nourishment and the fluids aided in stimulating the kidneys to remove toxins from the body. However, soldiers with massive bleeding saw only temporary 

improvement from IV fluid administration because the 

solution would quickly leave the peripheral vascular 

system. For soldiers suffering from severe shock, blood 

products including fresh whole blood or blood plasma 

were key in preventing death from shock and massive 

hemorrhage. The technology of “banking” blood products was newly introduced during this period, allowing 

blood and plasma to be safely stored up to 8 days prior 

to administration.14 Many injured soldiers on leave donated blood to “repay” the blood bank for blood they 

had received during the Pearl Harbor attacks.16

On the wards at Schofield Station Hospital, Lt. Girard 

prepared for the influx of patients by moving all of the 

hospital beds from the exterior porch and into the middle of the large ward. The patients on the convalescent 

wards all requested to be discharged so they could go 

to war. Patients arrived in the ward and again required 

triage; some went to the OR, others to the morgue, and 

some stayed for wound care and to await surgery at a 

later date. On many wards, the physicians were unable 

to examine the patients until that evening because they 

were busy stabilizing patients in and around the operating room, leaving the ward under the sole care of the 

nurses. By the time the physicians had arrived on the 

ward, the patients were all undressed, sorted, assessed, 

and stabilized by the nurses and corpsmen.7

Trauma Care at Pearl Harbor

For those Army Soldiers killed or injured, the primary 

mechanism of injury was the blast force and debris from 

the bomb, or crush injuries from structural collapse. The 

majority of injuries seen from an aerial bombardment 

consisted of multiple fractures, hemorrhage, and extensively torn muscles, with many of those injured rapidly 
116 http://www.cs.amedd.army.mil/amedd_journal.aspx

progressing into shock. The detonation of the half-ton 

bombs caused the steel jacket to be blown into small, 

sharp fragments at a high enough velocity and rotational 

force to carry them over 1500 yards. The combination 

of the forward and rotational momentum caused severe 

damage to the human tissue and bone with little external evidence of injury, with an estimated one-third of 

those wounded suffering mortal injuries. Those standing upright during the blast were most likely to be injured, with wounds to the legs being most common. The 

recommended treatment was to splint any fracture or 

suspected torn muscle, provide warm blankets, sedate 

with morphine, and rest. Those incurring more serious 

injuries involving the abdomen or chest would receive 

surgical treatment immediately with the goal of minimizing organ damage and internal bleeding.14

Crush injuries and compound fractures were common injuries among the Soldiers in Hawaii. Crush injuries were 

treated by immediately compressing the effected tissue 

with an elastic bandage with approximately 40-60 mm 

Hg of pressure. This would compress the tissue enough 

to decrease swelling, but would allow for blood flow to 

the injured tissue, preventing gangrene. Compound fractures were best treated in the operating theater; however, 

initial treatment involved splinting the affected bone, 

reducing the fracture if possible, applying sulfonamide 

powder to the wound, and covering with a dressing. Under normal circumstances, compound fractures are a 

high priority for surgery; however, due to the large number of critical cases, most orthopedic repairs had to wait 

24-72 hours. Despite this delay in treatment, no cases of 

gas gangrene or deaths from other infection occurred, 

which was a highly significant improvement in medical 

and surgical treatment compared to World War I.14

Wound care at the time heavily emphasized protection 

from bacteria and bleeding control. Bullets from the air 

strike were fired at an extremely high velocity, causing 

the entrance wounds to appear small, and exit wounds 

would be several times larger.7

 Direct pressure was applied for 2-3 minutes before bandaging to control bleeding. For most wounds, nurses would apply a pressure 

dressing using a dry, sterile dressing; a freshly-ironed 

handkerchief; or a clean towel. If a pressure dressing 

was inadequate to control the bleeding, a tourniquet was 

applied to either the upper arm or thigh with enough 

pressure to compress the artery against the bone. The 

tourniquet was loosened every 30 minutes to reassess 

the wound for bleeding. If the bleeding was controlled, 

direct pressure to the wound and a pressure dressing 

could be applied, restoring blood flow to and from the 

injured extremity. Wounds were not routinely irrigated 

due to the risk of re-bleeding; rather they would sprinkle 

3-10 grams of sulfadiazine into the wound, cover it with 

a dressing, and await surgery if needed.14

Other advances in wound care included packing and 

dressing wounds instead of closing them with sutures. 

This allowed the sterile packing material to absorb infectious drainage from the wound and decreased the 

incidence of wounds colonized with anaerobic bacteria, 

including the often fatal gas gangrene. There were only 

15 cases of gas gangrene from Pearl Harbor, all from 

wounds prematurely closed with sutures.14

Collaboration and Dedication

Soldiers and medical personnel reacted both positively 

and negatively to the enormous amount of physical, 

mental, and emotional stress experienced during and 

following the Pearl Harbor bombing. Generally, patients, volunteers, and staff had a positive attitude and 

were ready to help the efforts at Tripler, Schofield, and 

Hickam.7

 Officers’ wives, Red Cross volunteers, civilian 

nurses and doctors, patients, and even prostitutes came 

to the hospitals to volunteer. At Tripler and Schofield, 

untrained volunteers assisted the effort by making 2x2 

and 4x4 dressings, cotton balls, and swabs out of the 

bolts of gauze at the hospital; as well as cleaning, sterilizing, and preparing the instruments in the OR at all 

hours of the day and night.1,8,10 In Schofield, those patients almost ready for discharge volunteered by bringing sterile solutions to the OR. Lt. Clark later reflected 

that “everyone worked so well and functioned such as 

[she had] never seen, truly a team. They knew what 

to do. They knew how to do it.” 8

 Patients and officer’s 

wives also volunteered at Hickam to make dressings for 

Soldiers, even arriving in the middle of the raid to help.5

The physicians, nurses, medical corpsman, and volunteers worked together many hours past their shifts to 

ensure all of the patients were well-cared for, despite 

being understaffed and having no breaks. Lt. Girard recalls, “no one had to ask you to stay on. You just stayed 

on until your work was done...In the service, if you’re 

needed, you’re there. We don’t have to worry about 

overtime, that’s your job. We can work 10, 12, 14 hours 

and think nothing of it because [there] was something to 

be done.” 7

 Following the Pearl Harbor attack, Lt. Barron and two other nurses covered the Tripler emergency room for a 20-hour shift.1

 Nurses who had worked 

the night before stayed on until the afternoon, only to 

sleep and return less than eight hours later. In the OR 

at Schofield, Lt. Clark did not take a break until 6 pm

that evening, and stayed on until 4:30 am, only to start 

more cases early the next morning.8

 In many ways, the 

United States was unprepared and surprised by the attack on Pearl Harbor; however, the doctors and nurses 

Grace Under Fire: The Army Nurses of Pearl Harbor, 1941
October – December 2016 117

The Army Medical Department Journal

working in the Army facilities in Hawaii were able to 

swiftly care for the injured soldiers. “It was just a marvelous thing how they handled the emergency. We saved 

lives. It was something...They were just tremendous, 

and deserved to be recognized for their extraordinary 

work and efficiency.” 8

 The staff was able to put their 

own personal fears and fatigue aside, work together as a 

team, and take care of patients without complaint. The 

health care team was united under the common cause 

of saving the lives of the Soldiers who had sacrificed 

themselves for their country.7,8,10

In many ways, the United States was unprepared and 

surprised by the attack on Pearl Harbor; however, the 

doctors and nurses working in Hawaii that day were able 

to swiftly care for the injured Soldiers. In an interview 40 

years after the bombing, Clark shares her reflections about 

that day. “It was just a marvelous thing how they handled 

the emergency. We saved lives. It was something...They 

were just tremendous, and deserved to be recognized for 

their extraordinary work and efficiency.”8

 The staff was 

able to put their own personal fears and fatigue aside, 

work together as a team, and take care of patients without complaint. The health care team was united under the 

common cause of saving the lives of the soldiers who had 

sacrificed themselves for their country.7,8,10

The intersection of duty, resilience, and compassion 

shaped the nurses’ work at all three facilities, and their 

story is a testament to their dedication to others. The 

nurses serving in the Army hospitals at Pearl Harbor 

played a significant role in the opening hours of the Japanese attack in 1941. Through triage, collaboration, stabilization, compassion, and dedication, they saved hundreds of lives.

References

1. Gelane Barron [Interview], May 24, 1982, 2010.8.3, 5, 

Research Collection, US Army Medical Department 

Center of History and Heritage, Fort Sam Houston, Tx.

2. Army nurses of World War One: Service beyond 

expectations. Army Heritage Center Foundation. Available at: http://armyheritage.org/education-and-programs/educational-resources/soldierstories/130-army-nurses-of-world-war-one-ser

vice-beyond-expectations.html. Accessed September 

30, 2015.

3. Bellafaire JA. The Army Nurse Corps: A commemoration of World War II service. US Army Center 

of Military History. Available at: http://www.his

tory.army.mil/books/wwii/72-14/72-14.HTM. October 3, 2003. Accessed September 30, 2015.

4. Sarnecky MT. A History of the US Army Nurse Corps. 

Philadelphia, PA: University of Pennsylvania Press; 

1999. pgs. 175, 177.

5. Monica Conter Benning [Interview], May 26, 1982, 

2010.8.3, 8, Research Collection, US Army Medical 

Department Center of History and Heritage, Fort Sam 

Houston, Texas.

6. Mary Coberly Finn [Interview], May 24, 1982, 

2010.8.3, 31, Research Collection, US Army Medical 

Department Center of History and Heritage, Fort Sam 

Houston, Texas.

7. Pauline Girard [Interview], May 25, 1982, 2010.8.3, 

36, Research Collection, US Army Medical Department Center of History and Heritage, Fort Sam Houston, Texas.

8. Mildred Irene Clark [Interview], May 25, 1982, 

2010.8.3, 18A, Research Collection, US Army Medical Department Center of History and Heritage, Fort 

Sam Houston, Texas.

9. 50th Anniversary of World War II Commemoration 

Committee. Pearl Harbor: 50th anniversary commemorative chronicle: A grateful nation remembers, 

1941-1991. US Department of Defense; 1991. Available at: http://babel.hathitrust.org/cgi/pt?id=uiug.30

112046512148;view=1up;seq=1. Updated September 

28, 1992. Accessed September 30, 2015.

10. Kathryn M Doody [Interview], May 24, 1982, 

2010.8.3, 27, Research Collection, US Army Medical 

Department Center of History and Heritage, Fort Sam 

Houston, Texas.

11. Attacks on airfields and aerial combat. Naval History and Heritage Command. Available at: http://

www.history.navy.mil/our-collections/photogra

phy/wars-and-events/world-war-ii/pearl-harbor-raid/

attacks-on-airfields-and-aerial-combat.html. Accessed September 30, 2015.

12. Hawaii Aviation. Hickam Field. State of Hawaii Department of Transportation. Available at: hawaii.gov/

hawaiiaviation/hawaii-airfields-airports/oahu-preworld-war-ii/hickam-field-air-force-base. Accessed 

September 30, 2015.

13. Hawaii Aviation. Eye witness accounts of the 

bombing of Hickam AFB. Available at: http://

hawaii.gov/hawaiiaviation/world-war-ii/decem

ber-7-1941/first-hand-accounts-of-the-bombing-ofhickam-afb. Accessed September 30, 2015.

14. Cole W, Puestow C. First Aid: Surgical and Medical. 

2nd ed. London, UK: Appleton-Century Company; 

1943.

15. Mason VR. Medical Department United States Army 

in World War II. Chapter VII: Central Pacific Area, 

pg. 627. Available at: http://history.amedd.army.mil/

booksdocs/wwii/medconslt1/Ch07.html. Accessed 

September 30, 2015.

16. Paramount News. Sailor Repays Blood Bank 

[video]. GettyImages. Available at: http://www.

gettyimages.com/detail/video/caravan-arrivesat-hospital-red-cross-nurses-pull-can-news-foot

age/502796017. Published November 1, 1942. Accessed September 30, 2015.
118 http://www.cs.amedd.army.mil/amedd_journal.aspx

In 1905, Japan shocked the world by becoming the first 

Asian nation to defeat a western country on the field of 

battle since Genghis Khan and the Mongols. They simultaneously commanded the attention of the military 

medical community by claiming to be the first combatant force to suffer fewer deaths from disease than from 

enemy action. Given the recent, disease-ridden medical 

debacle of the Spanish-American War, American military medical reformers used Japan’s achievements as a 

model for the US Army Medical Department (AMEDD) 

to emulate.1

 After briefly defining Japan’s said success, 

this essay reviews the failures of the AMEDD in the 

Spanish American War. It then highlights how Japan, 

fighting less than a decade later, appeared to achieve 

dramatically different results. I conclude first by proving Japan’s medical victory fictitious and then by showing how AMEDD reformers nonetheless used the narrative of success to advance their own agenda in modernizing the department.

Japan’s Success and America’s Failure

Japan and her supporters proudly trumpeted its success 

controlling disease. Their victory on the field of battle 

was evident, driving the Russians out of Korea and 

Manchuria and claiming the territory for themselves.2

Their conquest over disease appeared equally obvious: 

Japan lost more men to battle than to disease. Numbers 

vary based on source consulted, but whereas 53,000-

59,000 men died from direct enemy action, only 12,000-

27,000 men died from illness.3

 While Japan and its allies claimed priority for this achievement, in fact the 

Prussians obtained a similar ratio 30 years earlier in the 

Franco-Prussian War.4

 Nonetheless, compared to most 

19th century wars where disease far outstripped combat 

deaths, Japan seemed to accomplish a monumental feat. 

(America, for example, did not achieve similar results 

until World War II.) Figure 1 shows the number of disease deaths per battle death in wars of the 19th century. 

The graph highlights Japan’s apparent success, and it 

was to graphs and comparisons of this type that Japan 

and her supporters pointed. Reality, as this essay will 

prove, was more complicated.

If the Russo-Japanese War was championed as a posterchild of military medical efficiency, the Spanish American War represented its alleged nadir. As Figure 1 also 

demonstrates, far more Soldiers died from disease in 

that conflict than from direct contact with the enemy.6

Combat medicine acquitted itself well, applying the 

germ theory of disease through antiseptic dressings 

and deploying new technology like x-rays to manage 

the combat-wounded; the died-of-wounds rate dropped 

from 17% in the Civil War to 4%. However, sanitation 

and public health failed the American Soldier. Bivouacked in camps that paid little heed to waste management, thousands of Soldiers suffered—and died—from 

diarrhea, 74% of which resulted from typhoid.7

 Until 

Walter Reed’s team proved the role of the mosquito as a 

vector for yellow fever, that disease ravaged US service 

members as well.8

 American volunteers who never left 

the United States also suffered grievously, as camps like 

Chickamauga became synonymous with death from diarrhea.9

 All told, over 2500 men died from disease, compared to 385 from combat.10

Military Medicine of the Russo-Japanese War

 and its Influence on the Modernization of the

 US Army Medical Department

Justin Barr, MD*

2015

Spurgeon Neel Annual Award Runner-up

The Army Medical Department Museum Foundation sponsors the Spurgeon Neel Annual Award 

competition for the best original article that best exemplifies the history, legacy, and tradition of 

the US Army Medical Department. The following article by Dr Justin Barr was selected as the 

second best submission of the 2015 competition.

*Dr Barr is with the Department of Surgery, Duke University Medical Center, Durham, North Carolina.
October – December 2016 119

The Army Medical Department Journal

The debacle of American military medicine in the Spanish American War spawned reform efforts in the Army 

Medical Department. In the immediate post-war years, 

searing public commentary led to the Dodge Commission investigating the reasons behind the failure of the 

Army and its medical support. Presented in February of 

1899, the Report delivered a fair, impartial accounting. 

Surgeon General William Sternberg and the AMEDD 

escaped most of the blame, with responsibility assigned 

to Congress for not funding the department adequately 

and restricting the number of regular Army physicians.11

This deficiency represented a general problem in the US 

military, with poor relations between line and staff officers; the two groups failed to work together in war, an 

issue not totally resolved until the Elihu Root’s restructuring of the Army.12 The Army kept enough line officers to command a 100,000-man army; however, it retained enough surgeons for only for 42,000 men.13 Contract surgeons hired to make up the difference had little 

experience in public health, contributing to the deadly 

diarrheal epidemics. Effective as physicians, they failed 

as military medical officers.14 Military surgeons from 

Sternberg on down wanted Congress to fund a reserve 

corps of Army doctors that would allow better trained 

Army physicians to deploy in time of war.15 They introduced multiple congressional bills demanding a larger, 

better trained cadre of uniformed physicians.16

AMEDD reformers used the apparent success of the Japanese to promote their agenda and provide evidence for 

the importance and efficacy of their suggested changes. 

“Other nations, including so poor a nation as the Japanese, are willing to pay the cost of increased efficiency 

in the shape of a large and well organized medical service,” noted Army Surgeon General Robert O’Reilly, 

implying that America should as well.17 Even outside 

military medicine, American Medical Association President William Mayo used the success of the Japanese as 

a fillip to improve civilian public health in this country.18

By 1907, The Surgeon General’s Index contained almost 

500 articles on the Russo-Japanese war, highlighting the 

attention it received in the medical community.

No one lionized the Japanese more than Louis L. Seamen. Having served as a volunteer surgeon in the Spanish American War, Seaman travelled to Manchuria as 

a quasi-official medical attaché to the Japanese during 

their war with Russia. He returned to publish gushing 

accounts of their ability to control disease.19 Seaman explicitly strove to force change in the AMEDD, dedicating 

his 1907 book: “To the Medical and Sanitary Officers 

of the Japanese Army, who have proved that the normal 

condition of the Soldier is health...; to that vast army of 

American Dead, whose lives in war have been needlessly 

sacrificed through preventable diseases, ignorance, and 

incompetency.” 20 He and others pointed to the sufficient 

number of Japanese medical officers, their training, and 

most importantly, their effective integration with line officers that allowed them to effect necessary public health 

measures, all features deemed lacking in the AMEDD.

Figure 1. Disease deaths per battle deaths by 19th century war and combatant, showing the apparent success, though not priority, of the Japanese.5

 FPW indicates Franco-Prussian War; SAW, 

Spanish American War; UK, United Kingdom; CSA, Confederate States of America. Disease Deaths per 1 Battle Death

War and Countries Involved

4

1

0

2

6

3

5

7

8

9

1.7

0.5 0.3 0.5

7.9

1

1.9

3.8

7.3

2.1

FPW SAW

Russia Union USA

Boer

War

Crimea

USA UK and CSA German UK Russia Japan

France

Mexican

War

US Civil War Russo-Japanese

War
120 http://www.cs.amedd.army.mil/amedd_journal.aspx

Part of the western acceptance of Japanese medicine 

stemmed from its adoption of modern germ-based 

medicine. Early Portuguese and Dutch traders to Japan 

contributed little medical knowledge, but the opening 

of Japan by Commodore Matthew Perry and especially 

the Meiji Restoration of 1868 provided an institutional 

and intellectual framework for western medicine to take 

hold.21 As Germany dominated medical research in the 

late 19th century, Japan emulated the Teutonic system. 

German professors like Karl Leopold Mueller travelled 

to Japan to establish a medical education system. Stellar 

Japanese students studied and worked in German laboratories. Kitasato Shibasaburo, perhaps the best known 

Japanese scientist, studied with Robert Koch, produced 

the first pure tetanus bacilli in 1881 and, along with Behring, proved the efficacy of the diphtheria antitoxin.22 He 

became world famous, sharing the star-billet with Joseph Lister at an 1891 London conference. Kitasato and 

colleagues like Ogata Masanori, who also studied with 

Koch and Max Petternkoffer, brought the gospel of bacteriology back to Japan, where it was widely accepted.23

Military medical officers applied this bacteriology to 

their public health efforts in the Russo-Japanese War. 

Efforts started in training camp, where the Japanese 

Surgeon General distributed pamphlets to each recruit 

instructing them to cook their food thoroughly, boil 

their drinking water, seek medical care early, and avoid 

contact with rats, fleas, and mosquitoes.24 These pamphlets explicitly based their recommendations on the 

germ theory of disease imported from Germany. The 

flyers also instructed Soldiers to keep themselves clean, 

and here the Japanese propensity for bathing greatly assisted in camp hygiene.25 This educational effort continued overseas, with medical officers delivering regular 

lectures to reinforce these concepts.26

In addition to (and arguably more important than) their 

role in treating combat wounded, Japanese medical 

officers at the front carried important public health responsibilities.27 Physicians accompanied foraging parties to check food quality; they inspected provisions; 

they established and monitored sewer and latrine systems in the camp; and when the Japanese captured a 

town, medical doctors accompanied some of the first 

troops occupying the village to ensure sanitation prevailed. They performed their jobs effectively because 

of their acceptance by line officers as subject-matter 

experts whose advice was to be heeded. This respect 

reflected Japan’s adoption of the Prussian Staff system, 

with its elevation of staff officers to a position equal to 

that of the line.

Japanese physicians’ most important task lay in maintaining a potable water supply.28 Per Surgeon General 

Shigemichi Suzuki, “the paramount importance of good 

water supply in military sanitation was recognized...

drinking unboiled water was strictly forbidden even 

in peace time and this rule was strenuously applied in 

the late war.” 29 The Japanese custom of tea consumption helped ensure boiled water.30 Medical officers also 

regulated well-water quality. When they came across a 

new water source, they used their bacteriology-based 

laboratory training to test its contents and regulate its 

use (see Figure 2).31 American reformers recognized 

the importance and proper emphasis on public health in 

the Japanese Army. Colonel John Hoff believed Japan’s 

success stemmed solely from the “observance of wellestablished hygienic rules [and] proper sanitary organization...this war has developed nothing new in medical 

treatment or surgical technique, its one lesson for us 

is summed up in a single word: prevention [emphasis 

original].” 32

The Japanese might have achieved greater success had 

they vaccinated their troops. Almroth Wright developed 

the typhoid vaccine in 1897. It was available to, but not 

mandatory for, the British Army during the Boer War. 

Figure 2. Left: signs posted at water sources in Japan indicating water purity. Right: an American attaché points to one such sign 

posted at a well. 

Military Medicine of the Russo-Japanese War and its Influence on

the Modernization of the US Army Medical Department
October – December 2016 121

The Army Medical Department Journal

About 5% of British Soldiers chose to be vaccinated; 

thousands of others perished from the disease.33 Given 

the impact of disease in the Spanish American and Boer 

Wars, typhoid commanded substantial attention in the 

military medical literature.34 Articles variously supported and decried vaccination.35 The Japanese opposed 

it, with Surgeon General Suzuki categorically stating 

that “preventive inoculations were not performed...preventive inoculation for typhoid fever, dysentery, cholera, 

and plague not yet being certain.” 36 Eschewing the cholera vaccine had minimal impact on their forces.37 They 

did mandate smallpox vaccinations and as a result suffered only 209 cases with 12 deaths from the disease.38

Based largely on the experience of the British and Japanese, the US Army became first to mandate typhoid vaccination in 1911.39

While the Japanese achieved measureable success 

against water-borne pathogens, their rations, specifically white rice, resulted in tens of thousands of unnecessary casualties. Beriberi had bedeviled Asian societies 

for centuries. By the late 19th century, a fierce etiological debate traversed Europe and Asia, with apostles of 

bacteriology claiming to identify a causative microorganism whereas other scientists insisted on a nutritional 

deficiency. (In 1896, Christiaan Eijkman proved the 

disease resulted from the lack of vitamin B1, though it 

took decades for his hypothesis to gain acceptance).40

Polished, white rice lacks vitamin B1; it was also more 

expensive and thus a status symbol in Japan. As such, 

for much of history only upper-class Japanese suffered 

from the disease. The Army and Navy, trying to elevate 

social position of soldiers and sailors, transitioned to 

polished, white rice in the late 19th century only to see 

the incidence of beriberi soar among their forces. Without identifying the precise etiology, the Japanese Navy 

recognized the correlation between white rice and the 

disease, added barley to their rations in 1886, and effectively eliminated the problem. The Japanese Army, however, remained wed to an infectious etiology and did not 

alter their rations until February of 1905.41 By then, over 

80,000 Japanese soldiers required evacuation from the 

theater for beriberi; around 10,000 of those men died.42

Conclusions: Varying Definitions of Success

The Japanese recognized and touted their military medical accomplishment. They claimed their ability to control disease was an essential factor in their victory over 

the numerically superior Russians:

Russia may be able to place 2,000,000 men in the 

field. We can furnish 500,000. You know that in every war four men die of disease for every one who 

falls from bullets. That will be the position of Russia 

in this war. We propose to eliminate disease as a 

factor. Every man who dies in our Army must fall 

in the field of battle. In this way we shall neutralize 

the superiority of Russian numbers and stand on a 

comparatively equal footing.43

In fact, Russian forces in theater did not outnumber the 

Japanese, and the Russians achieved similar success in 

controlling disease. Yet the continued perception of Japanese success not only elevated Japan’s standing among 

modern nations but also served as evidence for American military medical reformers. The conclusion of this 

article examines Japan’s claims of medical superiority—

and finds them wanting—while simultaneously demonstrating how Americans like Seamen used the notion of 

Japanese superiority to effect real change in the AMEDD.

While the Japanese undeniably lost more men to battle 

than to disease, a more sophisticated analysis of their casualty statistics undermine their claims of military medical superiority. Biostatistics as a field was just emerging in this era, with leaders like Karl Pearson, Francis 

Galton, and Charles Davenport, later infamous for their 

work on eugenics, devising and publishing powerful 

new methods of analyzing numerical data in their new, 

1901 journal Biometrika.

44 Applying even rudimentary 

biostatistics shows that the disease death:battle ratio is 

a poor metric for capturing the efficacy of a combatant’s medical service and leads to inaccurate conclusions when comparing one war against another. First, it 

does not account for either the size of the army or the 

length of the war. Reassessing Japan’s losses from disease while taking into account these variables reveals 

a notable lack of distinction. As Figure 3 shows, Japan 

lost proportionately the same number of men from disease as other 19th century combatants.

Secondly, the ratio ignores differences in battle deaths 

among wars, the crucial denominator in this fraction. 

The relative sanguinity of a conflict could make 20,000 

deaths from illness appear as either a disaster or triumph of military medicine. The high number of casualties the Japanese suffered offset their losses from sickness. Almost 60,000 Japanese Soldiers and sailors died 

from battle wounds, a rate of 54 deaths per 1000 men 

per year. As Figure 4 shows, this rate was higher than all 

other 19th century military engagements except for the 

Crimean and Franco-Prussian Wars.

The specific character of fighting in the Russo-Japanese 

War led to this high casualty rate. The combat forecast 

the trench warfare of World War I, with the Russians 

often occupying a fixed defensive position complete 

with water cooled machine guns, barbed wire-laced 
122 http://www.cs.amedd.army.mil/amedd_journal.aspx

fortifications, and modern, quick firing artillery 

batteries.45 Japan assaulted across no-man’s-land 

in rigid, Prussian formations, taking thousands of 

casualties. Even Ian Hamilton, a British military 

attaché to the Japanese who later commanded the 

disastrous landings at Gallipoli, reported “the 

Japanese are lavish with their brave infantry, and 

think little of losing two or three hundred men.” 46

The profligate casualties skewed the ratio of disease deaths:battle deaths and made Japanese 

military medicine appear more effective than it 

actually was.

Perceptions matter as much as reality in history, 

and the perceived notion of Japanese success following American failure helped catalyze reforms 

of the AMEDD.

47 Seaman certainly propagated 

this mantra of Japanese superiority, reporting 

numbers highlighting their achievement. Not all 

of Seaman’s contemporaries accepted his statistics even when they agreed with his overarching 

goal of AMEDD reform. Charles Stokes, the Surgeon General of the American Navy at the time, 

commented, “Dr. Seaman, whose aims seem perfectly proper, can do the cause of military surgery 

and military sanitation in this country no greater 

service than that of correcting his statistics and 

removing the wrong impressions some of his 

remarks have made.” 48 And Lewis Duncan later 

published an exhaustive review of casualty statistics in part to counter the “ridiculously false idea 

that the Americans in Spanish American War 

lost fifty-six times as many men by disease, proportionally, as the Japanese in their recent war.” 49

Despite some countervailing views, the trope of 

Japanese success persisted (and has endured into 

the present).50

The AMEDD successfully used this narrative to 

foster multiple reforms in the early 20th century. 

A 1901 reorganization of the AMEDD stemmed 

from deficiencies in the Spanish American War 

but failed to address numerical shortages and especially relations with the line.51 Japan’s apparent 

achievements in 1904-1905 provided new ammunition for reformers. With figures like Rough 

Rider Teddy Roosevelt arguing for the AMEDD 

in front of Congress, the legislative body added 

123 billets to the department in 1908. A reserve medical corps was established to avoid again relying on untrained contract surgeons.

Japan’s demonstration of the importance of sanitation 

to preserving their fighting force led to public health 

instruction for line officers. In 1905, the Secretary of 

War established a department of military hygiene at the 

United States Military Academy at West Point.52 In 1907, 

both the Army Staff College and the Army War College 

initiated courses on sanitation.53 These moves reflected 

military recognition of the salience of public health 

Figure 3. Death rates per 1000 men in the Army per year, demonstrating 

Japanese equivalence to other 19th century combatants, including the 

US Army in the Spanish American War. SAW indicates Spanish American 

War; UK, United Kingdom.

SAW

French USA Japanese

Boer

War

Franco-Prussian

War

Union German UK Russian

US Civil

War

Russo-Japanese

War

25.58

80

20

0

40

120

60

100

140

160

Deaths/1000/Annum

War and Countries Involved

13.5

25

140.8

24.51

65

25.73

Military Medicine of the Russo-Japanese War and its Influence on

the Modernization of the US Army Medical Department

30

10

50

0

40

20

60

80

70

SAW

French USA Japanese

Boer

War

Franco-Prussian

War

Union German UK Russian

US Civil

War

Russo-Japanese

War

35

54

War and Countries Involved

Deaths/1000/Annum

14

4.6

67.5

55

33

Figure 4. The rates of combat deaths, elucidating the high relative casualty rate suffered by the Japanese. SAW indicates Spanish American 

War; UK, United Kingdom.
October – December 2016 123

The Army Medical Department Journal

measures and further elevated the stature of uniformed 

physicians as specialists and equals who could provide 

the expertise necessary to keep an army intact.

These reforms contributed to the marked success of the 

AMEDD in World War I where the American Expeditionary Force managed to limit deaths from disease to 

fewer than those from combat.54 Victor Vaughan, who, 

along with Walter Reed had investigated the typhoid 

outbreaks at Chickamauga and again donned a uniform 

in 1917, remarked: “I served in the war with Spain in 

1898, and I went time and again to a division officer and 

made certain requests or offered certain advice. As a 

rule, I was snubbed...but in the late war [World War I] 

I had a different experience. I never went to a line officer with a recommendation but that he said, ‘Doctor, 

it will be done.’” 55 The perceived and propagandized 

ability of Japanese medical officers to protect troops led 

to reforms in the US Army and AMEDD that provided 

the foundation for this change in attitude and change 

in care, as uniformed American physicians could now 

fulfill their duty to preserve the fighting force.

Endnotes

1. British military medical reformers, embarrassed after 

the disease-ridden Boer War, did the same. See Claire 

Herrick, “The Conquest of the Silent Foe’: British and 

American Military Medical Reform Rhetoric and the 

Russo-Japanese War,” in Medicine and Modern Warfare, edited by Roger Cooter, Mark Harrison, and 

Steve Sturdy, 99-130 (Atlanta: Rodopi, 1999).

2. The best single volume history of the Russo-Japanese 

War remains Dennis and Peggy Warner, The Tide at 

Sunrise: a History of the Russo-Japanese War (New 

York: Charterhouse, 1974). 

3. For 53,000 battle deaths and 12,000 disease deaths, 

see Louis Livingstone Seaman, The Real Triumph of 

Japan: the Conquest of the Silent Foe (New York: D. 

Appelton and Co., 1907) 510. For 59,000 and 27,000, 

see Louis C. Duncan, “The Comparative Mortality of 

Disease and Battle Casualties in the Historic Wars of 

the World,” Journal of the Military Service Institution 

of the United States 54, no. 188 (1914): 172. 

4. Roger Cooter, “Of War and Epidemics: Unnatural 

Couplings, Problematic Conceptions,” Social History 

of Medicine 16 no. 2 (2003): 292. Duncan, “The Comparative Mortality of Disease and Battle Casualties in 

the Historic Wars of the World,” 169.

5. M. R. Smallman-Raynor and A. D. Cliff, War Epidemics (Oxford: Oxford University Press, 2004).

6. For the best history of military medicine in the Spanish 

American War, see Vincent J. Crillo, Bullets and Bacilli: The Spanish-American war and Military Medicine

(New Brunswick: Rutgers University Press, 2004). 

For coverage of the Philippines theater, see Warwick 

Anderson, Colonial Pathologies: American Tropical 

Medicine, Race, and Hygiene in the Philippines (Durham: Duke University Press, 2006), chapters 1 and 2. 

For an overview of the AMEDD in this era, see Mary 

C. Gillet, The Army Medical Department 1865-1917

(Washington DC: Center of Military History, 1995) 

chapters 5-11. J. T. H. Connor, “Before the World in 

Concealed Disgrace,’ Physicians, Professionalization 

and the 1898 Cuban Campaign of the Spanish American War,” in Medicine and Modern Warfare, edited by 

Roger Cooter, Mark Harrison, and Steve Sturdy, 29-58 

(Atlanta: Rodopi, 1999).

7. Crillo, Bullets and Bacilli, 138.

8. For a recent study examining the role of Yellow Fever 

in the Spanish American War, see Espinosa, Mariola. 

Epidemic Invasions: Yellow Fever and the Limits of 

Cuban Independence, 1878-1930 (Chicago: University 

of Chicago Press, 2009). Multiple works have examined Walter Reed’s efforts, including: Howard A. Kelly, Walter Reed and Yellow Fever, 2nd ed. (Baltimore: 

The Medical Standard Book Company, 1906) and John 

R. Pierce and Jim Writer, Yellow Jack: How Yellow Fever Ravaged America and Walter Reed Discovered Its 

Deadly Secret (New Jersey: John Wiley & Sons, 2005). 

9. Connor, “Before the World in Concealed Disgrace,” 

36-37.

10. “America’s Wars,” http://www.va.gov/opa/publications/

factsheets/fs_americas_wars.pdf (accessed 27 September 2015).

11. The AMEDD’s lack of control over supplies also 

damned their effort to provide adequate care. Stephen 

C. Craig, In the Interest of Truth: the Life and Science 

of Surgeon General George Miller Sternberg (Fort 

Sam Houston: Borden Institute Press, 2013) chapter 

12. Cirillo, Bullets and Bacilli, chapter 5. 

12. Russel F. Weigley, History of the United States Army

(New York: MacMillan, 1967).

13. Major W. C. Borden, “Minutes from the meeting of 

The Association of Military Surgeons,” Journal of the 

Association of Military Surgeons, Vol. 17 (1905-06): 

530. 

14. Anderson, Colonial Pathologies, 30-32. 

15. “Letter from George Sternberg to the Adjutant General 

of the Army,” Journal of the Association of Military 

Surgeons XIII (1903-04): 325-27. Azel Ames, “A Medical Reserve Corps for the Army of the United States,” 

Journal of the Association of Military Surgeons XVI 

(1904-05): 69-94. “Army Medical Reorganization,” 

Journal of the Association of Military Surgeons XVI 

(1904-05): 63. 

16. See, for example, “Bill for the Increase of the Medical 

Department of the Army,” Journal of the Association 

of Military Surgeons XII (1903-1904): 327-330.
124 http://www.cs.amedd.army.mil/amedd_journal.aspx

17. Quoted in Bobby A. Wintermute, Public Health and 

the U.S. Military: a History of the Army Medical Department, 1818-1917 (New York: Routledge, 2011) 158. 

See also Jefferson Randolph Kean, Journal of the Association of Military Surgeons XVIII (1905-06): 1-35.

18. William J. Mayo, “The Medical Profession and the 

Issues Which Confront It,” Journal of the American 

Medical Association XLVI, no. 23 (1906): 1737-1740.

19. Publications include: Louis Livingston Seaman, Shall 

Disease Triumph in Our Army? A Plea for Recognition 

of the Medical Department of the United States Army

(New York: American Defense Society, Inc, 1904). Seaman, From Tokyo Through Manchuria with the Japanese. Seaman, “Observations in the Russo-Japanese 

War.” Louis Livingston Seaman, “The Real Triumph 

of Japan or the Conquest of the Silent Foe.” Journal 

of the Association of Military Surgeons 17 (1905-06): 

500-30. Seaman, The Real Triumph of Japan. Louis 

Livingston Seaman, “The Prevention of Disease in 

the War: More Power for the Medical Department of 

the Army,” Pamphlet No. 25. (New York: American 

Defense Society, Inc., 1918). Louis Livingston Seaman, 

“Some of the Triumphs of Scientific Medicine in Peace 

and War in Foreign Lands, with Suggestions upon the 

Necessity of Important Changes in the Organization 

of the Medical Department of the United States Army.” 

(New York: A.R. Elliot Publishing Company, 1908).

20. Seaman, The Real Triumph of Japan, opening 

dedication.

21. Harold Cook, Matters of Exchange: Commerce, Medicine, and Science in the Dutch Golden Age (New Haven: Yale University Press, 2007) chapter 9. Andrew 

Gordon, A Modern History of Japan: from Tokugawa 

Times to the Present (New York: Oxford University 

Press, 2003) 61-76. Albert Craig, “The Central Government,” in Marius Jansen and Gilbert Rozman, eds, 

Japan in Transition (Princeton: Princeton University 

Press, 1986) 36-67.

22. Anna Jannetta has recently complicated this simplistic periodization by carefully examining the introduction of smallpox vaccination – western medicine 

in both theory and practice – in the early 19th century. 

See The Vaccinators: Smallpox, Medical Knowledge, 

and the “Opening” of Japan (Stanford: Stanford University Press, 2007). However, smallpox vaccination 

represents more the exception than the rule, with even 

Jannetta acknowledging that Japan’s emperor banned 

western medicine, except for vaccination; it did create 

a bridgehead that facilitated the introduction of bacteriology later in the century. 

23. William W. Ford, Bacteriology, (New York: Paul B. 

Hoeber, 1939) 114.

24. John Z. Bowers, When the Twain Meet: The Rise of 

Western Medicine in Japan (Baltimore: The Johns 

Hopkins University Press, 1980). 

25. Fluency in German was required of Japanese physicians so they could access the latest bacteriological research. “The Preparation of the Japanese Medical Officer,” Journal of the Association of Military Surgeons

18 (1905-06): 292-293.

26. Seaman, The Real Triumph of Japan, 167-68. Seaman 

provided a translated copy of the hand-out. 

27. Valery Havard, “The Sick and Wounded in the Russo-Japanese War,” Journal of the Association of Military Surgeons 17 (1905-06): 546. Seaman, The Real 

Triumph of Japan, 151-52. David Walder, The Short 

Victorious War: The Russo-Japanese Conflict 1904-

1905 (London: Hutchinson & Co., 1970) 223. Walder 

related a humorous anecdote where, during the winter 

time, Japanese Soldiers would sprint, naked, from the 

heated bath houses to their barracks across the freezing Manchuria plains – a show of true dedication to 

cleanliness!

28. Shigemichi Suzuki, “Note on the Sanitary Condition 

of the Imperial Japanese Army During the Late RussoJapanese War,” Journal of the Association of Military 

Surgeons XIX no. 5 (November 1906): 433. Suzuki 

was the Surgeon General of the Japanese Navy during 

the Russo-Japanese War. 

29. For the Japanese emphasis on preventive medicine and 

sanitation, see John van Rensselaer Hoff, “The Japanese as Military Sanitarians,” Journal of the Association of Military Surgeons XIV (1903-04): 379-80. 

30. Seaman, From Tokyo to Manchuria with the Japanese, 

232-33. Seaman, “Observations in the Russo-Japanese 

War,” 21-22. Seaman, The Real Triumph of Japan, 117, 

146-47. Friedrich Prinzing, Epidemics Resulting from 

Wars, (London: Oxford at the Clarendon Press, 1916) 

297. 

31. Suzuki, “Note on the Sanitary Condition of the Imperial Japanese Army During the Late Russo-Japanese 

War,” 434-35. 

32. John van Rensselaer Hoff, “Medico-Military Notes 

in Manchuria,” Journal of the Association of Military 

Surgeons XIX (1906): 112. “The Japanese and Russian 

Military Medical Matters,” Journal of the Association 

of Military Surgeons XIV (1903-04): 182. Prinzing, 

Epidemics Resulting From Wars, 297.

33. Seaman, The Real Triumph of Japan, 154. “A Report 

from Vice Admiral Kataoka, Commander in Chief 3rd

Squadron,” in M. Kinai, The Russo-Japanese War: 

Official Reports (Tokyo: The Shimbashido, 1905) 57. 

During the winter, the ground froze for several meters; 

this layer of frozen earth prevented ground water from 

seeping in and contaminating wells. Havard, “The 

Sick and Wounded in the Russo-Japanese War,” 538. 

34. Dysentery proved the most deadly infectious disease 

for Japan, killing over 6,000 Soldiers. “Prevalence 

of Disease: War and Infectious Disease Before 1914,” 

Military Medicine of the Russo-Japanese War and its Influence on

the Modernization of the US Army Medical Department
October – December 2016 125

The Army Medical Department Journal

Public Health Reports 56 (21 March 1941): 549. Kean, 

“The Prevention of Disease in the Army and the Best 

Method of Accomplishing that Result,” 33. Hoff, 

“Medico-Military Notes in Manchuria,” 121-28. Prinzing, Epidemics Resulting From Wars, 297. Seaman, 

The Real Triumph of Japan, 106. 

35. Hoff, “Medico-Military Notes in Manchuria,” 97-98.

36. Michael Worboys, “Almroth Wright at Netley: Modern Medicine and the Military in Britain, 1892-1902,” 

in Medicine and Modern Warfare, edited by Roger 

Cooter, Mark Harrison, and Steve Sturdy, 77-98 (Atlanta: Rodopi, 1999) 88-90. 

37. Much discussion in the medical and especially the 

military medical profession focused on typhoid and 

particularly on causation and vectors. For the seminal 

work at the time, see Walter Reed, Victor Vaughan, 

and Edward Shakespeare, Report on the Origin and 

Spread of Typhoid Fever in US Military Camps during 

the Spanish War of 1898 (Washington DC: Government Printing Office, 1904). See also the Enno Sander 

Prize winning essay by Frederick Smith, “The Differential Diagnosis of Typhoid Fever,” Journal of the 

Association of Military Surgeons XIV (1903-1904): 

69-94.

38. Some articles suggested an innate Japanese immunity 

to typhoid explained their ability to control the disease. 

“Some Considerations Connected with the Relative Immunity of the Japanese Armies from Typhoid Fever,” 

Lancet 165 no. 4264 (20 May 1906): 1365-66.

39. E. H. Wilson, “Anti-typhoid Inoculations,” Journal of 

the Association of Military Surgeons XIII (1903-04): 

79-80.

40. Compulsory vaccination was rare in all countries at 

this this time, with the practice being the subject of 

much debate. See, for example, Peter Baldwin, Contagion and the State in Europe, 1830-1930 (Cambridge: 

Cambridge University Press, 1999) chapter 4. 

41. Suzuki, “Note on the Sanitary Condition of the Imperial Japanese Army During the Late Russo-Japanese 

War,” 436. 

42. There is a suggestion that Japan did use some cholera vaccines (see “Prevalence of Disease,” 500), but 

no hard evidence to substantiate this claim. For a 

contemporary evaluation of cholera vaccination, see 

Edward Shakespeare, Report on Cholera in Europe 

and India, (Washington: Government Printing Office, 

1890) 502-03, 548-55, 576, 625-26, 629-30, 660, and 

especially Chapter VI, entitled “Preventive Inoculation of Cholera.”

43. Hoff, “Medico-Military Notes in Manchuria,” 129. 

Havard, “The Sick and the Wounded in the Japanese 

War,” 535. Seaman, The Real Triumph of Japan, 224-

35. Suzuki, “Note on the Sanitary Condition of the Imperial Japanese Army During the Late Russo-Japanese 

War,” 436. Seaman discusses the presence of a factory 

in Japan that produced the smallpox vaccination. 

44. Stanhope Bayne-Jones, The Evolution of Preventive 

Medicine in the United States Army, 1607-1939 (Washington DC: Office of the Surgeon General, 1968) 140.

45. Kenneth J. Carpenter, Beriberi, White Rice, and Vitamin B: A Disease, a Cause, and a Cure (Berkeley: 

University of California Press, 2000).

46. This insistence on a bacterial etiology for beriberi was 

not at all unique to the Japanese but rather represented 

a common view throughout Europe and America, too. 

K Codell Carter, “The Germ Theory of Disease, Beriberi, and the Deficiency Theory of Disease,” Medical 

History 21 (1977): 119-136. 

47. Alan Hawk, “The Great Disease Enemy, Kak’ke (Beriberi) and the Imperial Japanese Army,” Military Medicine 171 no. 4 (April 2006): 333-339.

48. Quoted in Seaman, From Tokyo through Manchuria 

with the Japanese, 240. Seaman does not provide a 

source for the quote.

49. David Salsburg, The Lady Tasting Tea: How Statistics 

Revolutionized Science in the Twentieth Century (New 

York: Henry Holt and Company, 2001). For more on 

medical statistics in the 19th century, see John M. Eyler, 

Victorian Social Medicine: the Ideas and Methods of 

William Farr (Baltimore: the Johns Hopkins University Press, 1979), especially chapter 2. Both accounts 

demonstrate the over-simplicity and thus inaccuracy 

of the battle deaths:disease deaths ratio, and thus its 

inappropriateness a metric of success for comparing 

wars. 

50. Hydraulic and mechanical recoil systems for artillery 

appeared in the 1870s, allowing for a higher rate of 

fire. Artillery caused twice as many casualties in this 

conflict as in the Franco-Prussian War, which medical authorities noticed and explored in their writings. 

For the role of artillery in the Russo-Japanese War, see 

especially General de Négrier, Lessons of the RussoJapanese War, translated by: E. Louis Spiers (London: 

Hugh Rees, Ltd. 1906) 42-54. Also, L. Z. Soloview, 

Actual Experiences in War: Battle Action of Infantry; 

Impressions of a Company Commander, translated by 

the War Department (Washington DC: United States 

Army General staff, 1906) 6. Francis Roger Sedgewick, The Russo-Japanese War: A Sketch: First Period – The Concentration (London: Swan Sonnenschien 

& Co., 1909) 192. Walder, The Short Victorious War, 

291. Hoff, “Medico-Military Notes in Manchuria,” 

131. Charles S. Butler, “Wounds Produced by Japanese 

Projectiles,” Journal of the Association of Military 

Surgeons 18 (1905-06): 284. Hoff, “Medico-Military 

Notes in Manchuria,” 136, 139. Seaman, From Tokyo 

to Manchuria with the Japanese, 48. Seaman, “The 

Real Triumph of Japan or the Conquest of the Silent 

Foe,” 541; H. Nimier, “Wounds by Artillery Projectiles, 
126 http://www.cs.amedd.army.mil/amedd_journal.aspx

Hand Grenades and Land Mines in the War in Manchuria,” Translated by Charles Wilcox. Journal of the 

Association of Military Surgeons XVIII (1905-06):166, 

122. 

51. Quoted in Sedgwick, The Russo-Japanese War: A 

Sketch, 191. See also Ian Hamilton, A Staff Officer’s 

Scrapbook During the Russo-Japanese War (London: 

E. Arnold, 1907). 

52. Jay Winter has pioneered the importance of historically contrived memory of war over factual reality. 

See, for example, his book Sites of Memory, Sites of 

Mourning: the Great War in European Cultural History (New York: Cambridge University Press, 1995).

53. See minutes to the meeting of the Association of Military Surgeons in Journal of the Association of Military 

Surgeon, Vol. 17, pp. 520-22 and p. 502.

54. Duncan, “Comparative Mortality of Disease and 

Battle Casualties,” 143. Specifically, he was arguing 

against “the absurd conclusion[s]” of by Homer Lea.” 

Lea’s arithmetic is correct, but Lea does not factor 

other variables into his equations. Seaman’s numbers 

corresponded closely with those of Lea. Interestingly, 

this essay won the Seaman Prize, even as it contradicted much of Seaman’s earlier work. It does not cite 

Seaman. 

55. Many modern military medical histories still accept 

Japanese medical victory – and priority – in the RussoJapanese War uncritically. See, for example, Carol R. 

Byerly, Fever of War: The Influenza Epidemic in the 

U.S. Army during World War I (New York: New York 

University Press, 2005) 51. Wintermute, Public Health 

and the US Military, 162. Gillet, The Army Medical 

Department, 1865-1917, 325.

56. Connor, “Before the World in Concealed Disgrace,” 50.

57. “Instruction in Hygiene at West Point,” Journal of the 

Association of Military Surgeons 17 (1905-06): 148. “A 

Department of Military Hygiene at West Point,” Journal of the Association of Military Surgeons 17 (1905-

06): 475.

58. Wintermute, Public Health and the U.S. Military, 169.

59. Mary C. Gillet, The Army Medical Department, 1917-

1941 (Washington DC: Center of Military History, 

2009) and Jonathan H. Jaffin, “Medical Support for the 

American Expeditionary Forces in France During the 

First World War,” MA thesis, Command and General 

Staff College, 1991.

60. Quoted in Paul Starr, The Social Transformation of 

American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry (New York: 

Basic Books, 1982), 141. Starr argues that this transformation also reflected the general rise in the respectability of the medical profession – military and civilian 

– over these years. See also Conner, “Before the World 

in Concealed Disgrace,” 50.

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Military Medicine of the Russo-Japanese War and its Influence on

the Modernization of the US Army Medical Department

During the US Civil War, minimal attention was given to sanitation and other basic hygiene conditions in the field. These photos 

depict a battlefield staging area for wounded Soldiers pending treatment and/or evacuation Photo courtesy of Borden Institute.
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should conform to those guidelines as closely as possible. Abbreviations/acronyms should be limited as much as possible. Inclusion 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, 

place of publication, publisher, year of copyright, and specific page numbers if cited.

• 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. 

Images submitted on slides, negatives, or copies of X-ray film will not be published. For clarity, please mark the top of each 

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. The authors’ names, ranks or academic/certification credentials, titles or positions, current unit of assignment, and contact 

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

Editor, AMEDD Journal

AMEDDC&S, DoTAA

3630 Stanley RD STE B0204 

JBSA Fort Sam Houston, TX 78234-6100
PIN: 200281-000